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?

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 explain?

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 ever had a reaction to dental anesthetic?

If yes, please explain?

Do you have a home water filtration system?

If yes, what type?

Has your child had any previous trauma to teeth?

If yes, please explain?

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 explain?

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

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

If yes, please explain?

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?

Please list.

Signature of Parent/Guardian:

Signature

Printed name:

Date