Child Medical/Dental History Form

Patient Name:*

Patient DOB:*

Parent/Guardian Name:*

Parent/Guardian Email:*

Parent/Guardian Phone:*

DENTAL HISTORY

Why did you bring the child to the dentist today?

Has the child ever taken Fosamax or any other bisphosphonate?

Yes
No

If so, when?

Is the child currently in pain?

Yes
No

Does the child require antibiotics before dental treatment?

Yes
No

Has the child ever had a serious/difficult problem associated with previous dental work?

Yes
No

Is the child's water fluoridated?

Yes
No

Is the child taking fluoridated supplements?

Yes
No

Has the child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?

Yes
No

Does the child brush his/her teeth daily?

Yes
No

Floss his/her teeth daily?

Yes
No

Child's Physician:

Physician Phone #:

Date of Last Visit:

Is the child currently under the care of a physician?

Yes
No

Please describe the child's current physical health:

Good
Fair
Poor

Please list all prescription/over the counter or herbal supplement drugs that the child is currently taking:

Allergies:

Latex
Metals/Nickel
Plastic

Aside from items listed above, please list all drugs/things that the child is allergic to:

MEDICAL HISTORY

Has the child experienced the following medical problems?

Abnormal Bleeding/Hemophilia

Yes
No

ADD/ADHD

Yes
No

AIDS/HIV+

Yes
No

Anemia

Yes
No

Any Hospital Stays/Operations?

Yes
No

Artificial Bones/Joints/Valves

Yes
No

Asperger Syndrome

Yes
No

Asthma

Yes
No

Autism

Yes
No

Cancer

Yes
No

Chicken Pox

Yes
No

Congenital Heart Defect

Yes
No

Convulsions

Yes
No

Diabetes

Yes
No

Epilepsy

Yes
No

Exposed to HIV, but Neg.

Yes
No

Handicaps/Disabilities

Yes
No

Hearing Impairment

Yes
No

Heart Murmur

Yes
No

Hepatitis

Yes
No

High Blood Pressure

Yes
No

Hives

Yes
No

Kidney Problems

Yes
No

Liver Problems

Yes
No

Low Blood Pressure

Yes
No

Lupus

Yes
No

Measles

Yes
No

Mitral Valve Prolapse

Yes
No

Mononucleosis

Yes
No

Prosthetics

Yes
No

Rheumatic Fever

Yes
No

Scarlet Fever

Yes
No

Skin Rash

Yes
No

Tuberculosis (TB)

Yes
No

Are the child's immunizations current?

Yes
No

Anything you would like to discuss with the Doctor in private?

Yes
No

Please discuss any serious medical problems the child experiences/ed:

Does/did the child experience any of the following?

Breast Fed

Yes
No

Chewing on Objects

Yes
No

Clenching/Grinding Teeth

Yes
No

Lip Sucking/Biting

Yes
No

Mouth Breather

Yes
No

Nail Biting

Yes
No

Nursing Bottle Habits

Yes
No

Speech Problems

Yes
No

Thumb/Finger Sucking

Yes
No

Tongue Cheek/Biting

Yes
No

Tongue Thrust

Yes
No

Used Pacifier

Yes
No

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Guardian **

Date **

OFFICE USE ONLY

I have verbally reviewed the medical/dental information above with the parent/guardian & patient named herein.

Signature of Dentist

Date

Dentist's Comments:

Medical History Update (In office only)

Has there been any change in your child's health status since their last visit?

If yes, please explain

Parent/Guardian Signature

Dentist Signature

Date

Has there been any change in your child's health status since their last visit?

If yes, please explain

Parent/Guardian Signature

Dentist Signature

Date

Comments

This field is for validation purposes and should be left unchanged.