Child’s physician:
Physician Address:
Is your child:
Is in good health?
Under a physician’s care?
Taking medications?
Medications + Dosage:
Medical History and Information
Date of last medical exam:
Physician Phone:
Yes
Yes
Yes
No
No
No
Has your child had any history of illness or difficulty with the following? (circle all that apply)
ANEMIA
ASTHMA
AUTISM
BEHAVIOR
PROBLEMS
CANCER
CEREBRAL
PALSY
DEVELOPMENTAL
DELAY
DIABETES
DRUG
REACTION
ENDOCRINE
LEARNING
DISABILITY
HIV + OR AIDS
HYDROCEPHALUS
HEARING
IMPAIRMENT
HEPATITIS
KIDNEY
HEADACHES
LUNG DISEASE
LIVER / GI
SYSTEM
SEIZURES
SPEECH
DISORDER
THYROID
TUMOR
VISION
MPAIRMENT
SIGNIFICANT
INJURIE(S)
CONGENITAL
BIRTH DEFECTS
FREQUENT
INFECTIONS
BLOOD
TRANSFUSION(S)
(date(s)________)
Allergies? (drug, food, LATEX, pollen)
Has your child been hospitalized or required surgery?
Which best describes your child’s personality ?
Yes
Normal
No
Difficult
BLEEDING
DISORDER
HEART DEFECT,
DISEASE OR
MURMUR
Dates
Nervous
Dental History
Previous or referring dentist:
Previous or referring dentist:
Date of last dental visit:
Date of last dental visit:
Purpose of visit:
Has your child complained about dental problems?
Any unhappy dental experiences?
Yes
Any injuries to the mouth, teeth or head?
Yes
Any mouth habit (thumb sucking, grinding, biting nails)?
Yes
Do you assist the child with brushing and/or flossing?
Yes
Is fluoride taken in any form (other than toothpaste)?
Yes
Does your child have any difficulty with the jaw joints, “TMJ”?
Yes
Shy
No
No
No
No
No
No
PARENT COMMENT: (Is there anything else about your child you think we should know?
I understand that the information I have given is correct to the best of my knowledge, that it will be held
in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s
medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Child’s name:
Relationship to patient:
Your signature:
Date:
Reviewed by:
Date: