Children's Medical History (Age 0-15 Years)

Patient's Name:* Nickname:*

Address:*

Home Phone:* Cell Phone:*

Date of Birth:* Age:*

Gender:*

Male Female Prefer not to disclose

Parent's or Guardian's Name:*

Emergency Contact:

Name:* Phone:*

Relationship to patient:* How did you hear about our office?*

Medical History Past and Present (Check all that apply):

Heart Murmur

Prolonged bleeding when cut

Ear aches

Cardiac/Heart Disease/Pace Maker

Glaucoma

Bad Breath

Rheumatic Fever

Stained teeth

Cold Sore/Fever Blister

Bleeding Gums

Nervous Disorder

Tumour/Cancer

Chicken Pox/Measles/Mumps

Tonsilitis

Asthma/Lung Disease

Tuberculosis

High or Low Blood Pressure

ADD/ADHD

AIDS/Hepatitis/Liver Disease

Metallic Implant, Shunts, Pins/Rods

Diabetes

Blood transfusion

Epilepsy

Thyroid Disease

Is the patient currently taking any medications? If so, please list the medications:

Has the patient recently been under the care of a physician?

Yes No

If so, for what reason and what is the name of the physician? Has the patient ever been hospitalized in the last 5 years? (if yes, please explain) Has the patient had a serious illness or operation? (if yes, please explain) Has the patient ever had difficulties in the dental office? (if yes, please explain)

Last dental visit: Last medical exam:

Name of Paediatrician or primary care physician:

Are all immunizations up to date? (DPT, diphtheria, tetanus, whooping cough, measles and polio)

Yes No

Please check any of the following that your child experiences:

Nail biting Thumb Sucking Speech problems

Tongue thrust Snoring

Has your child had a history of being under oxygen/general anesthesia?

Yes No

If so, any reactions or adverse effects?

Yes No

Do you have any concerns with your childs teeth?

Yes No

If yes, please explain

Does the child have a specific problem that needs attention?

Yes No

If so, please check if applicable:

Toothache

Orthodontics

Home Care instructions

Is your child a mouth breather?

Yes No

If so, when:

While asleep

While awake

Has your child ever had any injury to the face, mouth or teeth?

Yes No

If yes, please explain

Has your child experienced popping, clicking or limitation of movement in temporomandibular joint (TMJ)

Yes No

Does your child experience headaches on a regular basis?

Yes No

Oral hygiene habits:

Type of brush:

Electric Manual

Bristle type:

Extra soft Soft

Medium Hard

Toothpaste name: How often does your child floss? How often do your child brush?

Does your child use a water pick?

Yes No

Mouthwash?

Yes No

Does your child use fluoride products?

Yes No

Dental Insurance Information

Primary Insured's Name: Date of Birth: Insurance Company:

Group #: Policy #:

Relationship to subscriber:

Do you have dual coverage?

Yes No

Secondary Insured's Name: Date of Birth: Insurance Company:

Group #: Policy #:

Relationship to subscriber:

I give my consent for the dentist of this office to do a complete/emergency oral dental examination on the patient listed above. X-rays that are necessary to properly complete the exam may be taken. If a cleaning, fluoride treatment and oral hygiene instructions are to be included in the first examination, I will be informed. Any additional treatment received will be fully explained prior to starting treatment at each visit. I agree to inform the doctors of any changes in medical or Insurance information.

I authorize the release of any information relating to any dental claims and understand that I am personally responsible for all costs associated for the dental treatment that is performed on my child. By signing this, I agree that the medical history is filled out to the best of my knowledge and I accept financial responsibility for my child.

Parent/Guardian Signature (Please print and sign)*

Reset Signature