Pediatric Medical-Dental History 1.2
REASON FOR VISIT
PATIENT GENDER STATUS
Gender
MEDICAL HISTORY
ALLERGIES
GROWTH / DEVELOPMENT
CENTRAL NERVOUS SYSTEM
CARDIOVASCULAR SYSTEM
BLOOD or LYMPHATIC SYSTEM
RESPIRATORY SYSTEM
GASTROINTESTINAL SYSTEM
GENITOURINARY SYSTEM
ENDOCRINE SYSTEM
SKIN
EXTREMITIES
MEDICATIONS or TREATMENTS
DENTAL HISTORY
MY CHILD DRINKS
HABITS
PREVENTION
How often are teeth brushed per day?
How often are teeth flossed per day?
Water Type?