Child Medical Dental History

Does your child have a primary care physician or pediatrician*

YesNo

Primary Physician/Pediatrician Name

City, State

Last seen month/year?

Reason?

Next appointment month/year?

Last physical exam month/year?

Does your child see other physicians?

YesNo

Please list any other physicians your child sees

Physician Name 1 City, State 1 Reason 1
Physician Name 2 City, State 2 Reason 2

Has your child been hospitalized in the past 5 years?

YesNo

Please explain

Now or in the past, has your child had?*

	Yes	No	Don't Know/Understand
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Does your child eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Has your child ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?

Has your child had allergies or reactions to the following?*

	Yes	No	Don't Know/Understand
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (Benzocaine, Lidocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods

Please list any other medical conditions or allergies that your child may have

Have your child's relatives ever had bleeding disorders, diabetes, arthritis, severe allergies, or other genetic medical conditions?*

YesNo

Please explain

Does your child take any medications, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements?*

YesNo

Please list any medication, nutritional supplement, herbal medication or non-prescription medicines, including fluoride supplements that your child takes.

Medication 1 taken for Reason 1
taken for
taken for
taken for
Medication 5 taken forReason 5
Medication 6 taken forReason 6
Medication 7 taken forReason 7
Medication 8 taken forReason 8

Does your child chew/smoke tobacco or vape?*

YesNo

Does your child currently have (or ever had) a substance abuse problem?*

YesNo

	Yes	No	Don't Know/Understand
Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?

Child Medical Dental History

Patient Information

Parent/Guardian Information

Financial Responsibility

Your Child's Dental Information

Dental Insurance

Dental History

Orthodontic History

Medical Information

Medical History

Medication

Releases and Waivers