Patient Name:*Date of Birth: Date Format: MM slash DD slash YYYY Dental History What is the reason for today’s visit?Is this the child’s first visit to a dentist?YesNoWhen was the last dental visit?Has the child ever had any dental X-rays?YesNoHas your child ever had any injuries to the mouth, head or teeth?Has your child ever had any problem with dental treatment in the past?Has your child ever had any orthodontic treatment?What type of water does your child drink?City waterWell waterBottled waterFiltered waterHas your child ever received fluoride supplements?YesNoWhat age?How many times are the child’s teeth brushed per day?When?Has the child sucked his or her thumb, fingers, or pacifier?YesNoDoes the habit still exist?Does the child grind his or her teeth?YesNoMedical HistoryIs your child taking any prescription and/ or over the counter medications?YesNoPlease list :Is your child allergic to any medications?YesNoPlease list:Is your child allergic to any foods or materials?YesNoPlease listHas your child been hospitalized?YesNoWhen?Reason?Has your child had any history or ever been diagnosed with any of the following: Anemia Allergy/ Hay Fever Artificial heart valve Artificial joint/ limb Asthma Attention Deficit Disorder (ADT) Autism Behavior/ learning disabilities Epilepsy/ seizure Birth defects Bleeding Disorder Bone/ joint/ orthopedic problem Brain injury Cancer Cerebral Palsy Chemotherapy Chicken Pox Chronic sinusitis Cleft lip/ palate Diabetes Digestive disturbances Eye problems Fainting Growth problem Hearing loss/ aids Heart murmur Heart problem Heart surgery Hepatitis HIV+ / AIDS Hormonal disturbances Kidney problems Liver problems Measles Mumps Nervous disorders Pneumonia Rheumatic Fever Scarlet Fever Shunt Sickle cell anemia Tetanus Tuberculosis Other: Type:OtherPediatrician/ Physician NamePhoneParent dateSignature
