Medical History
Please complete one form per child. Thank you.
Child's First Name
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Patient's Last Name
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Preferred Name
Patient's Date of Birth
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Sex
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Female
Male
Patient Pediatrician
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Does your child have or has had any of the following?
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NO KNOWN HEALTH ISSUES
Acid Reflux or GERD
ADD/ADHD
Anemia
Asthma
Autism Spectrum Disorder
Bleeding Disorder or bleeds/bruises easily
Breastfeeding Problems/Difficulty (if applicable)
Cerebral Palsy
Difficulty Swallowing or Eating certain Textured Foods
Down Syndrome
Developmental Delay
Diabetes
Gags Easily
Hearing/Speech Problems or Delay
Heart Murmur
Heart Problems or Heart Surgery
Hepatitis
HIV/AIDS
Kidney Disease
Lip Tie Surgery or Tongue Tie Surgery
Liver Disease
Mouth Breather
MTHFR Mutation / Carrier (Please also mark if either parent has the MTHFR Mutation or is a Carrier)
Rheumatic Fever
Seizures
Tonsil or Adenoid Problems or Removal
Tuberculosis
Tumors/Cancer
Vision Problems
Snoring
Special Needs
Speech Problems
Other
If your child has or has had any of the above conditions, please explain.
Has your child ever had surgery or been hospitalized?
Yes
No
If yes, please explain:
Please list any allergies (i.e. medications, latex, foods, etc.):
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Please list any medications that your child takes:
Dental History
Please list the reason for your dental visit and any specific concerns that you may have:
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Please list the name of your child's previous dentist and approximate date of his/her last visit:
Has your child ever had any type of negative or adverse reaction to dental anesthetics or dental care? Please explain.
Does your child have any habits?
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NO HABITS
Thumbsucking
Finger Sucking
Pacifier
Grinding
Nail Biting
Other
If "Other" Please explain:
Has your child ever been seen by an Orthodontist (braces)?
Yes
No
Orthodontist Name (if Not Applicable pls put N/A)
We would like to respect your wishes. In all of our operatories, we have televisions on the ceilings. Please let us know if you would like your child to watch Kids Netflix during his or her appointment.
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Yes
No
Only during procedures such as fillings
If there is any way that we can make you or your child more comfortable during dental care, please let us know how we can help:
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Please type your name
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Signature
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Date
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