CHILD MED HISTORY - HEALTH/DENTAL FORM

PATIENT'S NAME*

First NameLast Name
DATE OF BIRTH*

MonthDayYear
Date
SEX*

MaleFemale
PARENT/ GUARDIAN NAME*

First NameLast Name
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE HOME

Area CodePhone Number
PHONE OFFICE

Area CodePhone Number
MOBILE

Area CodePhone Number
EMAIL*
example@example.com
Have you or patient had any of the following diseases or problems*

YesNo
1. Active TB,

2. Persistent Cough for longer than 3 wks

3. Cough that produces blood?

If you answered yes to any of the above, please stop & return this form to the front desk.
Has the child had any history of:

AnemiaCancerEpilepsyHIV/AIDSMononucleosisSickle CellArthritisCerebral PalsyFaintingImmunizationsMumpsThyroidAsthmaChicken PoxGrowth ProblemsKidneyRheumatic FeverTuberculosisBladderChronic SinusitisLatex AllergySeizuresBleeding DisordersDiabetesHeartLiverBones/JointsEar AchesHepatitisMeaslesHearingOther
NAME OF FAMILY DOCTOR

First NameLast Name
PHONE #

Area CodePhone Number
Parent's/Guardian's Signature
Is your child taking any prescription or over the counter drugs or vitamins?

YesNo
If yes, please list
Is your child allergic to any medications?

YesNo
Does your child any food allergies?

YesNo
How would you describe your child's eating habits?
Has your child ever had a serious illness?

YesNo
Has your child ever been hospitalized?

YesNo
Has your child ever had general anesthetic?

YesNo
Does your child have a history of any other illness?

YesNo
Does your child have any speech difficulties?

YesNo
Has your child ever had a blood transfusion?

YesNo
Is your child physically, mentally or emotionally impaired?

YesNo
Does your child experience excessive bleeding?

YesNo
Is you child currently being treated for any illness?

YesNo
Is this your child's first dental appointment?

YesNo
If not, when was their last visit?
Who was their last dentist?
Has your child had any problems with past dental treatment?

YesNo
Has your child ever had dental x-rays taken?

YesNo
Has your child ever suffered any injury to head, mouth or teeth?

YesNo
Has your child had any problems with eruption or shedding of his teeth?

YesNo
Has your child had any orthodontic treatment?

YesNo
What type of water does your child drink:

citywellbottledfiltered water
Does your child take Fluoride supplements?

YesNo
Is Fluoride toothpaste used?

YesNo
How many times are your child's teeth brushed per day?
Does or did your child suck their thumb, fingers or pacifier?

YesNo
At what age did your child stop bottle feeding? Age
Breast feeding? Age
Does your child participate in recreational activities?

YesNo
Note: We encourage you to discuss any and all relevant patient health issues prior to treatment.

I certify that I have given answers to the above questions to the best of my knowledge. I will not hold Dr. Sheikh or any of his staff responsible for any action they take or do not take because of errors or omissions that I may have made in completion of this form.
Parent's/Guardian's Signature *

Clear
Date:

MonthDayYear
Date
Should be Empty: