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Patient Forms
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Patient Forms
Child medical History
First Name
(Required)
Last Name
(Required)
Email
(Required)
Phone
(Required)
Current physical health is :
Good
Fair
Poor
Are you currently under the care of a physician?
(Required)
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
Diabetes
Yes
No
Heart Murmur
Yes
No
Snoring
Yes
No
Asthma
Yes
No
Dizziness
Yes
No
Hearing Impaired
Yes
No
HIV/AIDS
Yes
No
Congenital Heart Defect
Yes
No
Eyesight Issues
Yes
No
Learning/Behavior Issues
Yes
No
Hepatitis
Yes
No
Depression/Anxiety
Yes
No
Headaches
Yes
No
Seizures
Yes
No
Premed Required
Yes
No
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
Explain
Sealants Placed
Yes
No
Baby teeth removed
Yes
No
Explain
History of Cavities
Yes
No
Issues with past dental treatment
Yes
No
Explain
Nitrous Oxide
Yes
No
Does your child
Eats Candy
Yes
No
Chews Gum
Yes
No
Drinks 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 :
Consent
(Required)
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.
(Required)
Date
(Required)
MM slash DD slash YYYY
