Home Child medical history Form Child medical history Form Phone First Name * Last name * Phone * Email * Current physical health is : * Good Fair Poor Are you currently under the care of a physician? * 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 Asthma * Yes No Congenital Heart Defect * Yes No Depression/Anxiety * Yes No Diabetes * Yes No Dizziness * Yes No Eyesight Issues * Yes No Headaches * Yes No Heart Murmur * Yes No Hearing Impaired * Yes No Learning/Behavior Issues * Yes No Seizures * Yes No Snoring * Yes No HIV/AIDS * Yes No Hepatitis * Yes No Premed Required * Yes No Hepatitis Type : 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 Baby teeth removed * Yes No Issues with past dental treatment * Yes No Explain Explain Explain Sealants Placed * Yes No History of Cavities * Yes No Nitrous Oxide * Yes No When does your child brush his/her teeth? * Morning After Meals Before Bedtime Does your child Eat Candy * Yes No Chew Gum * Yes No Drink Soda * Yes No 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 : 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. Here * Date
