Child's Name _________________________________
Birth date ____________ Phone #_________________
Is the child under the care of a Physician? [] yes [] no
Why? _______________________________________
What medications or pills is the child currently taking?
________________________________________
Is the child allergic to any medications or substances?
[] Aspirin [] Codeine [] Penicillin [] Latex [] Sulfa
[] Other ______________________________________
Child's Health History
Has the child experienced the following?
Rheumatic fever
Heart murmur
Mitral valve prolapse
Any heart problem
Asthma
AIDS/ HIV
Diabetes
Cancer/ Tumors
Chemotherapy
Jaw Joint Problems
Epilepsy / seizures
Fainting/ Dizziness
Hemophilia
Hepatitis
Yes No
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Please list any medical condition not listed
above.
_________________________________________
Has the child been instructed to pre-medicate with
antibiotics before receiving dental care? [] yes [] no
Child Dental History
Reason for today’s visit? _____________________________________________________________________
Describe any dental problems that the child may have _____________________________________________
When was the child’s last dental check-up? ____________ When was a panoramic x-ray taken? ___________
How would you rate the child’s tooth brushing? [] good [] fair [] poor [] very poor
How often does the child brush? _________________ Does the child use a power tooth brush? [] yes [] no
Has the child been seen by an orthodontist? [] yes [] no
Other concerns _____________________________________________________________________
Does the child have any of the following habits? (please check)
[] Drinks soda daily
[] Eats sweets between meals
[] Chews gum / eats candy
[] Uses breath mints
[] Sucks thumb or pacifier
[] Goes to bed without brushing
I understand that the information I have given is correct. I authorize treatment of required dental services and
release of information for medical consultation and referral, as well as insurance submission. I also understand
that it is my responsibility to inform this office of any changes the child’s medical status.
__________________________________________________________________________________________
(signed) (Relationship to the child) (Date)
Does the child play sports? [] yes [] no Does the child wear a protective mouth guard? [] yes [] no
Type of water the child drinks? [] City water [] Well water [] Bottled water w/ fluoride
[] Bottled water no fluoride Are fluoride supplements taken? [] yes [] no
Is there any additional information that we should know about the child? ________________________________
__________________________________________________________________________________________