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Patient Forms

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Patient Forms

Child medical History

Name

First Name *

Last name *

Email *

Phone *

Current physical health is :

Good Fair Poor

Are you currently under the care of a physician? *

Yes No

If yes, please explain

Physician Name

Clinic Name

Is your child allergic to any of the following?

Amoxicillin

Erythromycin

Penicillin

Aspirin

Jewelry

Sulfa Drugs

Codeine

Latex

Dental Anesthetics

Other

other :

Please list all current medications:

Has the child experienced any of the following?

Acid Reflux

Yes No

Asthma

Yes No

Congenital Heart Defect

Yes No

Depression/Anxiety

Yes No

Diabetes

Yes No

Dizziness

Yes No

Eyesight Issues

Yes No

Headaches

Yes No

Heart Murmur

Yes No

Hearing Impaired

Yes No

Learning/Behavior Issues

Yes No

Seizures

Yes No

Snoring

Yes No

HIV/AIDS

Yes No

Hepatitis

Yes No

Premed Required

Yes No

Hepatitis Type :

Others :

Dental History

Last Dental Visit

Last X-rays taken

Has your child ever had any of the following:

Injuries to mouth/teeth

Yes No

Baby teeth removed

Yes No

Issues with past dental treatment

Yes No

Explain

Sealants Placed

Yes No

History of Cavities

Yes No

Nitrous Oxide

Yes No

Does your child

Eat Candy

Yes No

Chew Gum

Yes No

Drink Soda

Yes No

When does your child brush his/her teeth?

Morning After Meals Before Bedtime

Does your child floss?

Yes No

If Yes , How often :

How does your child receive fluoride?

Community Water Fluoride Drops/Tablets Fluoride Rinse/Gel Well water

Other Concerns :

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.

Here *

Date *

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