CHILD MEDICAL + DENTAL HISTORY FORM TODAY'S DATE * MM DD YYYY PATIENT'S NAME * First Name Last Name PREFERRED NAME * CHILD DENTAL HISTORY * HAS YOUR CHILD SEEN A DENTIST BEFORE? YES NO PREVIOUS / PRESENT DENTIST * How do you think your child will act toward the dentist today? * What is your childs current dental health? * GOOD FAIR POOR Has your child ever had an unfavorable experince in a previous dental (or Medical) office? * YES NO Does your child do any of the following? * Thumb/Finger Sucking Tongue Thrusting/Sucking Heavy Snoring Mouth Breathing Lip Sucking/Bitingteet grinding extended nursing Has Mother or Father had alot of dental decay? * YES NO DOES THE CHILD HAVE ANY LOOSE TEETH? * YES NO Has THE child experienced injuries to the mouth, teeth or Jaw? * YES NO PLEASE EXPLAIN Has your child been seen or treated by an orthodontist? * YES NO IF YES, NAME OF ORTHODONTIST DOES THE CHILD BRUSH THEIR OWN TEETH? * YES NO DOES THE CHILD FLOSS THEIR OWN TEETH? * YES NO DO YOU BRUSH OR FLOSS THE CHILD'S TEETH? * YES NO IS THE CHILD'S TEETH SENSITIVE TO ANY OF THE FOLLOWING? * HOT COLD SWEETS IS THE CHILD INVOLVED IN ANY CONTACT SPORTS? * YES NO MEDICAL HISTORY * CHECK ANY CONDITION BELOW THAT THE CHILD HAS EXPERIENCED: *Allergy Not listed *No Epinephrine .Alzheimer's disease .Dementia Acid Reflux a-Fib Allergy - Latex Allergy- Codeine Allergy Metal Allergy- Penicillin Allergy- Sulfa Allergy-Aspirin Allergy-Tetracyclin Anemia Anxiety Arthritis Arthritis-Rheumatoid Artificial Joints Aspirin Therapy Asthma Birth Control Med Birth Control Meds Bleeding easily Blood Disease Blood Pressure-High Blood Pressure-low Blood Thinner Cancer Chemotherpy Chronic Cough Chronic Fatigue Chronic Pain Colitis/Chron's/IBS COPD COVID19 CPAP Depression Diabetes Dizziness Epilepsy Fainting Fibromyalgia Glaucoma Hay Fever Headache/migraine Hearing loss Heart attack Heart Defects Heart Disease Heart Murmur Heart pacemaker Heart palpations Heart stents placed Heart valuve replace Hepatitis Herpes/Fever Blister High Cholesterol HIV+/AIDS hormone replacement Hyper Active/ADD Insomnia Intestinal disorder Kidney Disease Liver Disease Lupus Medication OTC Medication Prescribe Mental Disorders Mitral ValveProlapse Nervous Disorders Osteoporosis Pregnant Radiation Treatment Rheumatic Fever Seizures Shortness of breath Sinus Problems Sleep Disorder/Apnea Smoke/Vape/Chew Snoring Stroke Substance Abuse Thyroid Disease TMJD- jaw pain Tuberculosis Tumors/Growths Ulcers Please list any medications you are currently taking, one medication per line: * Physicians's Name, Phone # and Date last physical exam: * IS THE CHILD currently under the care of a physician? * YES NO if yes please explain DOES THE CHILD Need for antibotics prior to dental treatment? * YES NO NOT SURE if yes, please explain the medical condition antibiotics are being taken for. Please List any additional medical condition(s) not listed above AUTHORIZATION * I affirm the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover. By checking this box, I acknowledge that I have read this statement and agree to the contents. Thank you!
