Pediatric Medical-Dental History 1.2
REASON FOR VISIT
What is the reason for this visit?
PATIENT GENDER STATUS
Child's Primary Doctor:
Any allergies to medicines?
Any hypersensitivities to Latex?
Any other allergies?
GROWTH / DEVELOPMENT
Any learning, behavioral or communication problems?
Has had counseling or will in the future?
Any complications with pregnancy / child birth (premature)?
Any Growth Problems?
CENTRAL NERVOUS SYSTEM
Any history of cerebral palsy, seizures, loss of consciousness, or concussions?
Any injuries to the head?
Any sensory disorders? (seeing, hearing, touch)?
Any history of congenital heart disease, heart murmur, high blood pressure or rheumatic fever?
Has any heart surgery been done or recommended?
BLOOD or LYMPHATIC SYSTEM
Has your child ever had a blood transfusion, blood products or been exposed to HIV?
Bruises easily, frequent nosebleeds or bleeds easily from cuts?
Any history of anemia or sickle cell disease?
Is your child susceptible to infections?
Any history of pheumonia, asthma, cystic fibrosis, or lung diseases?
Any history of stomach, intestinal, or liver problems?
Any history of hepatitis or jaundice?
Any history of eating disorders or unintentional weight loss?
Any history of urinary tract infections, bladder, or kidney problems?
Any history of diabetes or thyroid disorders?
Any history of hormone replacement?
Any history of skin problems, cold sores, or canker sores?
Any Arthritis (joint problems)?
Any limitations of use of arms or legs - muscle weakness / muscular dystrophy?
MEDICATIONS or TREATMENTS
Medication or Treatment #1
Times per Day #1
Medication or Treatment #2
Times per Day #2
Medication or Treatment #3
Times per Day #3
Medication or Treatment #4
Times per Day #4
Ever received radiation / chemotherapy or diagnosed with cancer?
Does your child have a toothache or other problem?
Ever have an injury to the mouth, teeth, or jaw?
Is this their first visit to the dentist?
Is this their first visit to the dentist? If No, Date:
Is this their first visit to the dentist? If No, Dentist:
Ever have an unfavorable dental experience?
Is (was) your child nursed beyond 1 years old?
MY CHILD DRINKS
My Child Drinks: Milk
My Child Drinks: Pop / Soda
My Child Drinks:Juices
My Child Drinks: Water
Sucks Thumb / Fingers
Goes to Bed with Bottle / Sippy Cup
How often are teeth brushed per day?
How often are teeth flossed per day?
Are teeth inspected after the child brushes?
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