Child Dental/Medical History Step 1 of 3 33% Patient's Name(Required) First Middle Initial Last Nickname Patient's Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent’s Guardian’s Name(Required) First Last Dental History1. Is this your child’s first visit to a dentist?(Required) Yes No 2. 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?(Required) Yes No 4. Does your child eat between meals?(Required) Yes No 5. Does your child eat sweets, such as candy, soda pop, chewing gum?(Required) Yes No 6. When does your child brush his/her teeth?(Required) Upon arising After eating any food Right after meals Before going to bed 7. How does your child receive Fluoride?(Required) Community water Well water Fluoride drops or tablets Fluoride rinse or gel 8. Have any cavities been noted in the past?(Required) Yes No 9. Does your child suck his/her thumb or fingers?(Required) Yes No 10. Were any teeth (baby or permanent) removed by extraction?(Required) Yes No Was it suggested that the space be maintained?(Required) Yes No Was an appliance placed?(Required) Yes No 11. Have there been any injuries to teeth, such as falls, blows, chips, etc?(Required) Yes No If so describe(Required) 12. Has your child had any problem with dental treatment in the past?(Required) Yes No 13. Has anyone in the family, including parents, had orthodontics?(Required) Yes No 14. Has your child ever received a local anesthetic?(Required) Yes No 15. Has your child ever had occlusal sealants?(Required) Yes No 16. Does your child think there is anything wrong with his/her teeth?(Required) Yes No Medical History1. Does your child have a health problem? Yes No 2. Is your child under care of physician?(Required) Yes No If yes, since when and why?(Required) 3. Name of Physician(Required) 3. Phone # of Physician(Required) 4. Is your child receiving any medication?(Required) Yes No What medication?(Required) 5. Is your child allergic to penicillin, antibiotics or other drugs?(Required) Yes No 6. Is your child allergic to or sensitive to any metals or latex?(Required) Yes No 7. Does your child have other allergies?(Required) Yes No 8. Has your child had any serious illness?(Required) Yes No When?(Required) What?(Required) 9. Has your child ever had surgery?(Required) Yes No 10. Does your child have a heart murmur?(Required) Yes No 11. Is surgery contemplated?(Required) Yes No 12. Does your child experience severe or prolongated bleeding?(Required) Yes No 13. Does your child have AIDS or has he/she tested HIV positive?(Required) Yes No 14. Has your child tested positive for hepatitis?(Required) Yes No 15. Is your child subject to nervous disorders?(Required) Yes No If so,(Required) Fainting? Seizures? Dizziness? Behavioral/Learning problems? 16. Does your child have frequent headaches?(Required) Yes No 17. Has your child had history of:(Required) 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 None of the above "I certify that the above information is complete and accurate"(Required) By typing your full name here, you are electronically signing this document.Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Δ Child Dental/Medical History Step 1 of 3 33% Patient's Name(Required) First Middle Initial Last Nickname Patient's Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent’s Guardian’s Name(Required) First Last Dental History1. Is this your child’s first visit to a dentist?(Required) Yes No 2. 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?(Required) Yes No 4. Does your child eat between meals?(Required) Yes No 5. Does your child eat sweets, such as candy, soda pop, chewing gum?(Required) Yes No 6. When does your child brush his/her teeth?(Required) Upon arising After eating any food Right after meals Before going to bed 7. How does your child receive Fluoride?(Required) Community water Well water Fluoride drops or tablets Fluoride rinse or gel 8. Have any cavities been noted in the past?(Required) Yes No 9. Does your child suck his/her thumb or fingers?(Required) Yes No 10. Were any teeth (baby or permanent) removed by extraction?(Required) Yes No Was it suggested that the space be maintained?(Required) Yes No Was an appliance placed?(Required) Yes No 11. Have there been any injuries to teeth, such as falls, blows, chips, etc?(Required) Yes No If so describe(Required) 12. Has your child had any problem with dental treatment in the past?(Required) Yes No 13. Has anyone in the family, including parents, had orthodontics?(Required) Yes No 14. Has your child ever received a local anesthetic?(Required) Yes No 15. Has your child ever had occlusal sealants?(Required) Yes No 16. Does your child think there is anything wrong with his/her teeth?(Required) Yes No Medical History1. Does your child have a health problem? Yes No 2. Is your child under care of physician?(Required) Yes No If yes, since when and why?(Required) 3. Name of Physician(Required) 3. Phone # of Physician(Required) 4. Is your child receiving any medication?(Required) Yes No What medication?(Required) 5. Is your child allergic to penicillin, antibiotics or other drugs?(Required) Yes No 6. Is your child allergic to or sensitive to any metals or latex?(Required) Yes No 7. Does your child have other allergies?(Required) Yes No 8. Has your child had any serious illness?(Required) Yes No When?(Required) What?(Required) 9. Has your child ever had surgery?(Required) Yes No 10. Does your child have a heart murmur?(Required) Yes No 11. Is surgery contemplated?(Required) Yes No 12. Does your child experience severe or prolongated bleeding?(Required) Yes No 13. Does your child have AIDS or has he/she tested HIV positive?(Required) Yes No 14. Has your child tested positive for hepatitis?(Required) Yes No 15. Is your child subject to nervous disorders?(Required) Yes No If so,(Required) Fainting? Seizures? Dizziness? Behavioral/Learning problems? 16. Does your child have frequent headaches?(Required) Yes No 17. Has your child had history of:(Required) 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 None of the above "I certify that the above information is complete and accurate"(Required) By typing your full name here, you are electronically signing this document.Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Δ
