Form

MEDICAL AND DENTAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, the mouth is a part of your entire body. Health problems that your child may have, or medication they may be taking, could have an important interrelationship with the dentistry they will receive. Thank you for answering the following questions.

First Name

Last Name

Date Of Birth

Gender

Address

City

Zip Code

Phone

Siblings

Child's Physician

Physician's Phone

Has your child ever been hospitalized or had a major operation?

Please explain

Is your child taking any prescription medications?

Medication Name

Does your child have any known allergies? If yes, please explain

Please explain allergies

Does your child have any of the following?

Liver Disease

Visual Problems

Lung Disease

Diabetes

Asthma

Cancer

Kidney Problems

Heart Murmur

Tuberculosis

Hearing Problem

Epilepsy or Seizures

Thyroid Disease

Down Syndrome

Bleeding/Blood Disorder

AIDS/HIV Positive

Autism Spectrum Disorder

Musculoskeletal Problems

Heart Problems

Breathimg Problems

Prematurity/NeoNatal Issues

Emotional/Mental Problems

Other (Please Explain)

Is this the first visit to the dentist?

If No, when was your chid's last dental exam?

Were X-Rays taken?

Name of former Dentist

City

State

Date of last Xrays, If known:

Does your child drink any of the following:

At What age did you start brushing your child's teeth?

How many times per day?

Does your child spit or swallow the toothpaste

Does your child use dental floss?

Does your child use a Fluoride supplement or other mouth rinse? (rinse,tablet)

If Yes, what type?

Whar brand of toothpaste does your child use?

Has your Child had an unfavorable Medical or Dental experience?

If Yes, please describe

Please add anything concerning medical or dental history you feel may be important:

Whom Shall we contact regarding your child's appointments?

Patient referred by:

I certify that I have read and I understand the questions asked. I certify I have answered these questions in completion and do not hold the practice, doctor(s), or team responsible for any errors or omission that I have made in completing these forms. I consent to the diagnostic procedures and treatment by the dentist(s) of this office necessary for proper dental care.

PLEASE NOTE: PARENT OR LEGAL GUARDIAN MUST BE PRESENT FOR THE INITIAL APPOINTMENT.

Signature (Parent or Guardian)

Date