Small Smiles Medical History 2020
Personal Information
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.
Special Concerns
Do any of the following apply to your child?
Does your child, or has your child had, any of the following?
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.