Child Dental/Medical History form Child Dental/Medical History Step 1 of 3 33% Patient's Name First Middle Last Nickname Patient's Date of Birth Date Format: MM slash DD slash YYYY Parent’s Guardian’s Name First Last Dental History1. Is this your child’s first visit to a dentist? . .YesNo2. If not, how long since the last visit to the dentist?3. Were any x-rays or radiographs taken when your child previously visited the dentist?YesNoDon't KnowDoes your child eat between meals?YesNoDon't Know4. Does your child eat between meals?YesNoDon't Know5. Does your child eat sweets, such as candy, soda pop, chewing gum?YesNo6. When does your child brush his/her teeth? Upon arising After eating any food Choice Right after meals Before going to bed 7. How does your child receive Fluoride? Community water Well water Fluoride drops or tablets Fluoride rinse or gel 8. Have any cavities been noted in the past?YesNo9. Does your child suck his/her thumb or fingers?YesNo10. Were any teeth (baby or permanent) removed by extraction?YesNo Was it suggested that the space be maintained?YesNoWas an appliance placed?YesNo11. Have there been any injuries to teeth, such as falls, blows, chips, etc?YesNoIf so describe12. Has your child had any problem with dental treatment in the past?YesNo13. Has anyone in the family, including parents, had orthodontics?YesNo14. Has your child ever received a local anesthetic?YesNo15. Has your child ever had occlusal sealants?YesNo16. Does your child think there is anything wrong with his/her teeth?YesNo Medical History1. Does your child have a health problem?YesNo2. Is your child under care of physician?YesNoIf yes, since when and why?3. Name and Phone # of Physician4. Is your child receiving any medication?YesNoWhat medication?5. Is your child allergic to penicillin, antibiotics or other drugs?YesNo6. Is your child allergic to or sensitive to any metals or latex?YesNo7. Does your child have other allergies?YesNo8. Has your child had any serious illness?YesNoWhen and What Illness?9. Has your child ever had surgery?YesNo10. Does your child have a heart murmur?YesNo11. Is surgery contemplated?YesNo12. Does your child experience severe or prolongated bleeding?YesNo13. Does your child have AIDS or has he/she tested HIV positive?YesNo14. Has your child tested positive for hepatitis?YesNo15. Is your child subject to nervous disorders? Yes No Fainting? Seizures? Dizziness? Behavioral/Learning problems? 16. Does your child have frequent headaches?YesNo17. Has your child had history of: (Check appropriate responses) diabetes heart trouble asthma kidney infection rheumatic fever epilepsy cerebral palsy liver problems congenital birth defects mental retardation eyesight problems cancer infections speech impairments hearing loss. "I certify that the above information is complete and accurate"* First Last By typing your full name here, you are electronically signing this document.