Form

Small Smiles Medical History 2020

First Name

Last Name

Personal Information

Date of Birth:

Although dental personnel primarily treat the area in and around your mouth, your child's mouth is a part of their entire body. Health problems that your child may have, or medication that your child may be taking, could have an important interrelationship with the dentistry they will receive. Thank you for answering the following questions.

Is your child under a physician's care now?

If Yes

Has your child ever been hospitalized or had a major operation?

If Yes

Is your child taking any medications, pills, or drugs (including over the counter)? If yes, please list:

If Yes

Does your child have any mouth habits (ie finger/thumb sucking, lip/nail biting, pacifier)?

If Yes

Has your child had any unfavorable reaction from previous dental or medical care?

If Yes

Are antibiotics necessary because of a heart defect, prosthesis, or other medical reason(s)?

If Yes

Is your child allergic to any of the following?

Other?

If Yes

Special Concerns

Do any of the following apply to your child?

Autism

Aspergers

Sensory Processing Disorder

Developmental Delay

Speech Delay

Anxiety

Depression

ADD

ADHD

Down Syndrome

Speech Apraxia

Hearing Impairment

Brain Injury

Tourette's Syndrome

Bipolar Disorder

Obsessive Compulsive Disorder

Cerebral Palsy

Cleft Lip/Palate

Birth Defect

Adopted

Wheelchair

Other?

If Yes

Does your child, or has your child had, any of the following?

AIDS/HIV Positive

Hemophilia

Hepatitis A

Anaphylaxis

Hepatitis B or C

Anemia

Herpes

High Blood Pressure

Epilepsy or Seizures

Artificial Heart Valve

Excessive Bleeding

Hives or Rash

Hypoglycemia

Sickle Cell Disease

Asthma

Fainting Spells/Dizziness

Sinus Trouble

Blood Disease

Kidney Problems

Leukemia

Stomach/Intestinal Disease

Frequent Headaches

Liver Disease

Low Blood Pressure

Cancer

Thyroid Disease

Mitral Valve Prolapse

Tonsillitis

Cold Sores/Fever Blisters

Heart Murmur

Pain in Jaw Joints

Tumors or Growths

Congenital Heart Disorder

Heart Pacemaker

Parathyroid Disease

Psychiatric Care

Diabetes Type I

Diabetes Type II

Juvenile Arthritis

Pregnancy

Insulin Pump

MRSA

Cochlear Implant

Metal Implant/Pins/Rods

Has your child ever had any serious medical conditons not listed above?

If Yes

Is there anything you feel we should know about your child?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to the patient's health. It is my responsibility to inform the dental office of any changes in medical status.

Patient, Parent or Guardian