New Pt Medical History Form

PATIENT'S FULL NAME

First NameLast Name

MIDDLE INITIAL

NICKNAME

SEX

AGE

DATE OF BIRTH

Date

SCHOOL

GRADE

REASON FOR VISIT

REFERRED TO THIS OFFICE BY (We wish to thank them)

CHILD'S PHYSICIAN

DATE LAST SAW PHYSICIAN

MONTH/YEAR

CITY

PHONE NUMBER

Area CodePhone Number

IS YOUR CHILD PRESENTLY UNDER THE CARE OF A PHYSICIAN FOR ANY MEDICAL REASON?

YESNO

WHAT?

PHYSICIAN NAME & PHONE #

IS YOUR CHILD CURRENTLY TAKING ANY MEDICATION?

YESNO

WHAT?

HAS YOUR CHILD EVER BEEN HOSPITALIZED OR HAD SURGERY?

YESNO

FOR WHAT?

IS YOUR CHILD ALLERGIC TO ANY FOOD OR MEDICINE?

YESNO

WHAT?

ADHD / ADD

YESNO

ANEMIA

YESNO

ALLERGIES

YESNO

ASTHMA / BREATHING ISSUES

YESNO

AUTISM SPECTRUM

YESNO

BLEEDING DISORDER

YESNO

BRAIN INJURY

YESNO

CANCER / MALIGNANCY

YESNO

CARDIAC DISEASE / MURMUR

YESNO

CEREBRAL PALSY

YESNO

CHEMO / RADIATION

YESNO

CYSTIC FIBROSIS

YESNO

DELAYED DEVELOPMENT

YESNO

DEPRESSION / ANXIETY

YESNO

DIABETES

YESNO

DOWN'S SYNDROME

YESNO

EARACHES / INFECTIONS

YESNO

EMOTIONAL / SCHOOL ISSUES

YESNO

EPILEPSY / SEIZURE

YESNO

HEARING IMPAIRMENT

YESNO

HEPATITIS

YESNO

IMMUNE DISORDER

YESNO

KIDNEY / LIVER ISSUES

YESNO

MUSCULAR DISORDER

YESNO

PREMATURE BIRTH

YESNO

RHEUMATIC FEVER

YESNO

SPEECH DISORDER

YESNO

TUBERCULOSIS

YESNO

VISUAL IMPAIRMENT

YESNO

DOES YOUR CHILD HAVE ANY DISEASE, CONDITION, OR PROBLEM NOT LISTED?

YESNO

IF SO, WHAT?

CHILD'S FIRST DENTAL VISIT?

YESNO

PREVIOUS DENTIST

CITY

PHONE #

DATE OF LAST VISIT

Date

DATE OF LAST X RAY

Date

ANY INJURIES TO YOUR CHILD'S TEETH OR JAWS?

YESNO

WHAT?

ANY HISTORY OF (SELECT ALL THAT APPLY):

HAS YOUR CHILD EXPERIENCED ANY UNFAVORABLE REACTION FORM PREVIOUS MEDICAL OR DENTAL CARE?

YESNO

EXPLAIN:

NAME OF FAMILY DENTIST

CITY

PHONE #

HOW OFTEN DOES YOUR CHILD BRUSH?

IS TOOTHBRUSHING SUPERVISED?

YESNO

BY WHOM?

IS DENTAL FLOSS USED?

YESNO

Type a question

To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.

SIGNATURE

Clear

PRINTED NAME

RELATIONSHIP TO PATIENT

Patient Medical History Form

MEDICAL HISTORY

HAS YOUR CHILD HAD A HISTORY OF:

DENTAL HISTORY