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Joy C. Arend, DMD

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Child Dental/Medical History

Step 1 of 3

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Patient's Name(Required)
MM slash DD slash YYYY
Parent’s Guardian’s Name(Required)

Dental History

1. Is this your child’s first visit to a dentist?(Required)
3. Were any x-rays or radiographs taken when your child previously visited the dentist?(Required)
4. Does your child eat between meals?(Required)
5. Does your child eat sweets, such as candy, soda pop, chewing gum?(Required)
6. When does your child brush his/her teeth?(Required)
7. How does your child receive Fluoride?(Required)
8. Have any cavities been noted in the past?(Required)
9. Does your child suck his/her thumb or fingers?(Required)
10. Were any teeth (baby or permanent) removed by extraction?(Required)
Was it suggested that the space be maintained?(Required)
Was an appliance placed?(Required)
11. Have there been any injuries to teeth, such as falls, blows, chips, etc?(Required)
12. Has your child had any problem with dental treatment in the past?(Required)
13. Has anyone in the family, including parents, had orthodontics?(Required)
14. Has your child ever received a local anesthetic?(Required)
15. Has your child ever had occlusal sealants?(Required)
16. Does your child think there is anything wrong with his/her teeth?(Required)

Medical History

1. Does your child have a health problem?
2. Is your child under care of physician?(Required)
4. Is your child receiving any medication?(Required)
5. Is your child allergic to penicillin, antibiotics or other drugs?(Required)
6. Is your child allergic to or sensitive to any metals or latex?(Required)
7. Does your child have other allergies?(Required)
8. Has your child had any serious illness?(Required)
9. Has your child ever had surgery?(Required)
10. Does your child have a heart murmur?(Required)
11. Is surgery contemplated?(Required)
12. Does your child experience severe or prolongated bleeding?(Required)
13. Does your child have AIDS or has he/she tested HIV positive?(Required)
14. Has your child tested positive for hepatitis?(Required)
15. Is your child subject to nervous disorders?(Required)
If so,(Required)
16. Does your child have frequent headaches?(Required)
17. Has your child had history of:(Required)
By typing your full name here, you are electronically signing this document.
Date(Required)

From the Blog

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  • COVID-19 Letter from East Portland Dentistry
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Our Location

9 NE 120th Ave,
Portland, OR 97220
Phone: (503) 447-8347
Alt Phone: (503) 255-2424
Email: [email protected]

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