Form

Pediatric Medical-Dental History 1.2

Patient First Name

Patient Last Name

REASON FOR VISIT

What is the reason for this visit?

PATIENT GENDER STATUS

Gender

Male

Female

Non-binary

Trans

MEDICAL HISTORY

Child's Primary Doctor:

Doctor's Phone#:

Specialist Doctor:

Specialist's Phone#:

ALLERGIES

Any allergies to medicines?

If Yes

Any hypersensitivities to Latex?

Any other allergies?

If Yes

GROWTH / DEVELOPMENT

Any learning, behavioral or communication problems?

If Yes

Has had counseling or will in the future?

If Yes

Any complications with pregnancy / child birth (premature)?

If Yes

Any Growth Problems?

If Yes

CENTRAL NERVOUS SYSTEM

Any history of cerebral palsy, seizures, loss of consciousness, or concussions?

If Yes

Any injuries to the head?

If Yes

Any sensory disorders? (seeing, hearing, touch)?

If Yes

CARDIOVASCULAR SYSTEM

Any history of congenital heart disease, heart murmur, high blood pressure or rheumatic fever?

If Yes

Has any heart surgery been done or recommended?

If Yes

BLOOD or LYMPHATIC SYSTEM

Has your child ever had a blood transfusion, blood products or been exposed to HIV?

If Yes

Bruises easily, frequent nosebleeds or bleeds easily from cuts?

If Yes

Any history of anemia or sickle cell disease?

If Yes

Is your child susceptible to infections?

If Yes

RESPIRATORY SYSTEM

Any history of pheumonia, asthma, cystic fibrosis, or lung diseases?

If Yes

GASTROINTESTINAL SYSTEM

Any history of stomach, intestinal, or liver problems?

If Yes

Any history of hepatitis or jaundice?

If Yes

Any history of eating disorders or unintentional weight loss?

If Yes

GENITOURINARY SYSTEM

Any history of urinary tract infections, bladder, or kidney problems?

If Yes

ENDOCRINE SYSTEM

Any history of diabetes or thyroid disorders?

If Yes

Any history of hormone replacement?

If Yes

SKIN

Any history of skin problems, cold sores, or canker sores?

If Yes

EXTREMITIES

Any Arthritis (joint problems)?

If Yes

Any limitations of use of arms or legs - muscle weakness / muscular dystrophy?

If Yes

MEDICATIONS or TREATMENTS

Medication or Treatment #1

Dosage #1

Times per Day #1

Medication or Treatment #2

Dosage #2

Times per Day #2

Medication or Treatment #3

Dosage #3

Times per Day #3

Medication or Treatment #4

Dosage #4

Times per Day #4

Ever received radiation / chemotherapy or diagnosed with cancer?

If Yes

DENTAL HISTORY

Does your child have a toothache or other problem?

If Yes

Ever have an injury to the mouth, teeth, or jaw?

If Yes

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?

If Yes

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

HABITS

Sucks Thumb / Fingers

Pacifier

Goes to Bed with Bottle / Sippy Cup

If Yes

Teeth grinding

PREVENTION

How often are teeth brushed per day?

None

Once

Twice

Three Times

How often are teeth flossed per day?

None

Once

Twice

Three Times

Are teeth inspected after the child brushes?

Water Type?

City Water

Well Water