Sutton - Medical History Form (Pediatric Dentistry)

Medical History Form (Pediatric Dentistry)
Patient's Name:*
DOB:*
Physician/Specialists
Last seen by primary care physician/pediatrician
Reason
Most recent physical exam*
Has you child received regularly scheduled immunizations?*

YesNo
Has your child ever been seen by a specialist (i.e. cardiologist, ENT, etc.)*

YesNo
Please list any specialists your child has seen (i.e. cardiologist, ENT, etc.)
Name
City, State
Reason
Name
City, State
Reason
Name
City, State
Reason
Medical History
Is your child in good health?*

YesNo
Please explain:
Does your child have any drug allergies?*

YesNo
List any medication allergies and reaction:
Does your child have any allergies (food or environmental)*

YesNo
Please explain:
Is your child taking any medications at this time?*

YesNo
Please list:
Has your child ever been hospitalized or treated in an emergency room for any particular trauma?*

YesNo
Please explain:
Have your child's tonsils and/or adenoids been removed?*

YesNo
Does your child breathe through the mouth?*

YesNo
If yes,

SeldomOften
Does your child snore?*

YesNo
Please indicate if your child has had any of the following:

AnemiaBleeding DisorderDiabetesHyperactivity/ADD/ADHDLatex Allergy/SensitivityPhysical handicapAsthmaBone DisorderEndocrine DisorderHeart Ailment or MurmurLiver Problems/HepatitisPositive for HIVAutism/ Asperger's SyndromeCleft PalateEpilepsy/SeizuresIntellectual DisabilityMalignancies/LeukemiaRadiation TreatmentRheumatic FeverSpeech Problem
Please comment on any problems that were checked in the above areas:
Would you like to update your preferred appointment day/time?

YesNo
Preferred appointment day

AnyMondayTuesdayWednesdayThursdayFriday
Time

AnyEarly/Late Morning (8:00am-12:00pm)Early Afternoon (12:00pm-3:00pm)Late Afternoon (3:00pm-5:00pm)
Should be Empty: