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Child medical history Form

Child medical History

"*" indicates required fields

First Name*

Last Name*

Email*

Phone*

Current physical health is :

Good

Fair

Poor

Are you currently under the care of a physician?*

Yes

If yes, please explain

Physician Name

Clinic Name

Is your child allergic to any of the following?

Other :

Please list all current medications:

Has the child experienced any of the following?

Acid Reflux*

Yes

Diabetes*

Yes

Heart Murmur*

Yes

Snoring*

Yes

Asthma*

Yes

Dizziness*

Yes

Hearing Impaired*

Yes

HIV/AIDS*

Yes

Congenital Heart Defect*

Yes

Eyesight Issues*

Yes

Learning/Behavior Issues*

Yes

Hepatitis*

Yes

Depression/Anxiety*

Yes

Headaches*

Yes

Seizures*

Yes

Premed Required*

Yes

Others :

Dental History

Last Dental Visit

Last X-rays taken

Has your child ever had any of the following:

Injuries to mouth/teeth*

Yes

Explain

Sealants Placed*

Yes

Baby teeth removed*

Yes

Explain

History of Cavities*

Yes

Issues with past dental treatment*

Yes

Explain

Nitrous Oxide*

Yes

Does your child

Eats Candy*

Yes

Chews Gum*

Yes

Drinks Soda*

Yes

When does your child brush his/her teeth?

Morning

After Meals

Before Bedtime

Does your child floss?*

Yes

If Yes , How often :

How does your child receive fluoride?

Community Water

Fluoride Drops/Tablets

Fluoride Rinse/Gel

Well water

Other Concerns :

Consent*

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.*

Date*

RiverRock Dental in Shakopee, MN is a multi specialty dental clinic. Our dentists, Dr. Todd Christianson and Dr. Andrew Backes hold over a decade of collective clinical expertise to provide quality specialized dental care at affordable price. Each member of our team is dedicated to ensuring that our patients are well-informed and comfortable at all times. At RiverRock Dental, we will never begin a treatment or procedure until all of your questions have been answered and you feel relaxed and at ease. To give you the best possible services and results, we are committed to continual education and learning. Being member of various dental association’s helps us to stay abreast of the changes and recommendations for our profession.

Child medical history Form