Child Medical and Dental History Date * Email Address * Child's Name * Preferred Name * Parent or Guardian * Child's Birthday * Gender * Male Female Reason for Visit * Child's Pediatrician * Pediatricians Phone # * Has child been seen by a physician in the last year? * Yes No Has child ever been hospitalized? * Yes No Has child ever had surgery? * Yes No List Current Medications Is child allergic to any medications? * Yes No Indicate Allergies Any other allergies? * Yes No Has child ever had any of the following? ADD/ADHD * Yes No AIDS (HIV) * Yes No Anemia/Blood Problems * Yes No Arthritis * Yes No Asthma * Yes No Autism * Yes No Bed Wetting * Yes No Bleeding Problems * Yes No Cerebral Palsy * Yes No Chicken Pox * Yes No Cleft Lip / Palate * Yes No Cold Sores / Herpes * Yes No Diabetes * Yes No Down Syndrome * Yes No Emotional Problems * Yes No Eye Problems * Yes No Hearing Problems * Yes No Heart Murmur * Yes No Heart Problems * Yes No Hepatitis A, B, or C * Yes No High Blood Pressure * Yes No Hyperactivity * Yes No Kidney Problems * Yes No Learning Disability * Yes No Liver Problems * Yes No Measles / Mumps * Yes No Mental Retardation * Yes No Mitral Valve Prolapse * Yes No Mouth Breathing * Yes No Object / Fingernail Biting * Yes No Psychiatric * Yes No Physical Handicap * Yes No Rheumatic Fever * Yes No Speech Problems * Yes No Seizures / Epilepsy * Yes No Sickle Cell Problems * Yes No Thumb Sucking * Yes No Thyroid Problems * Yes No Tongue Thrust * Yes No Tuberculosis * Yes No Tumor / Cancer * Yes No Yellow Jaundice * Yes No Is there anything not listed above that we should know about your child? Has there ever been any injury to any of the teeth or mouth? If yes, please explain. How often does child brush his/her teeth? Do you help your child brush? At what age did child get first tooth? Walk? Talk? Did child ever take a bottle to bed at night? At what age did child stop using the bottle? Has any member of your family had any unusual dental problems? To the best of my knowledge the above questions have been accurately answered. Parent/Guardian Signature (Please print name) * Relationship to Patient * Date * Submit Δ
