Form

Patient Health History (Alerts Corrected)

Patient First Name

Patient Last Name

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

Is your child under a physician's care now (excluding regular check-ups)?

If Yes

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

If Yes

Has your child had to take any type of antibiotic prior to dental procedures in the past?

If Yes

Is your child taking any medications, pills, or drugs?

If Yes

Is your child allergic to any medicines or foods?

If Yes

Is your child on a special diet?

If Yes

Does your child have any of the following conditions? Mark all that apply.

ADHD/ADD

Down Syndrome

Hemophilia or Bleeding Disorder

Muscular Dystrophy

Allergy

Eating Disorders

High or Low Blood Pressure

Neural Tube Defects

Anemia

Ectodermal Dysplasia

HIV or AIDS

Osteogenesis Imperfecta

Arthritis/Bone Disorder

Emotional Disturbance

Immune Disorders

Rheumatic Fever

Asthma

Epilepsy or Convulsions

Infective Endocarditis

Sleep Apnea

Autism

G-Tube

Kidney Problems

Spina Bifida

Bone Marrow Transplant

GERD

Liver Problems/Hepatitis

Thyroid or Endocrine Disorder

Cancer/Radiation/Chemo

Hearing or Vision Loss

Lupus

Tuberculosis or Mononucleosis

Cerebral Palsy

Heart Disease

Mental Disability

Wheel Chair Bound

Chronic Sinusitis

Heart Murmur

Mitochondrial Disorders

Other

Diabetes

Hydrocephalus

Have you ever had any serious illness not listed above?

If Yes

Physician Information

Pharmacy Information

Previous Dental History

Name of previous dentist:

Month/Year last visit:

Date of last bitewing x-ray:

Reason for leaving:

How often does your child visit the dentsit?

My child's attitude toward dentistry is:

Favorable

Unfavorable

Apprehensive

What is the purpose of your chlid's dental visit today?

Routine Care

Mouth or Tooth Pain

Trauma To Teeth / Gums

Comments:

I understand that the information that I have given is correct to the best of my knowledge and that it will be held in the strictest confidence. It is also my responsibility to inform this office of any changes in my child's medical status. I authorize Dr. Jan Carlson and any members of her team to perform the necessary dental services my child may need.

Patient, Parent or Guardian