Form

MEDICAL HISTORY

Child's First Name

Last Name

Date Of Birth

Allergies

Please list:

Anemia

Asthma

Bleeding

Heart Murmur

Seizures

Was pregnancy less than full term?

Has your child been hospitalized since birth?

If yes, please describe:

Is you child taking any medications, INCLUDING OTC?

Please list:

Do you have concerns about your child's speech? Have they been tested?

If yes, please describe:

Teens/Young Adults: pregnant or possibly pregnant?

Any medical conditions not stated above that should be brought to our attention:

Please list:

DENTAL HISTORY

Reason for today's visit:

Do you have any concerns you would like to talk to the dentist about today?

Please list:

Is this your child's first dental visit?

If no, when was the last visit and where?

Has your child had any previous trauma to teeth?

If yes, please describe:

Is your child under the care of an orthodontist?

If yes, who?

Has your child ever had trouble with previous dental care?

If yes, please describe:

Does your child have pain in his/her jaw joint?

Is child experiencing any pain in his/her mouth/teeth?

If yes, please describe:

Does your child have bad breath?

Any nail biting, thumb sucking, pacifier or lip sucking/biting habits?

Is your child a mouth breather?

Any clenching or grinding of teeth?

Frequent bottle use/sleeps with a bottle at night?

Any missing or extra teeth?

How often does child brush/floss?

Signature of Parent/Guardian:

Signature

Printed name:

Date