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Child Details
Child's full name
Birth date
Age
Male
Female
Medical physician
Medical physician phone number
Date Of Last Medical Exam ?
Height(feet)
Weight(lbs)
Details
Check for Yes
Problems
Details
Has your child ever been hospitalized, had general anesthesia,or emergency room visits?
Is your child up to date on all recommended immunizations for their age?
Is your child in good health at this time?
Is your child experiencing any pain or discomfort at this time?
Does your child have a latex allergy?
Does your child have any anxiety about seeing the dentist?
Does your child have or has previously had the following? If any are marked “Yes” please use additional space to explain.
Check for Yes
Problems
Details
Frequent cold or ear infections
Strep throat or tonsillitis
Tubes placed in ears
Pneumonia or respiratory problems
Tuberculosis
Seasonal allergies
Allergies to food or medication
Asthma
Sensory problems
Learning or communication problems
Emotional or behavioral problems
ADD/ADHD (list medication or vitamins)
Stomach problems or frequent vomiting
Liver disease hepatitis or jaundice
Diabetes, thyroid, or endocrine problems
Autism syndrome
Asperger syndrome
Cerebral palsy, seizures, convulsions, or fainting
Skin rashes or growths
Regular injections or medications
Radiation therapy
Heart murmur or disease
Does your child need a premed
High or low blood pressure
Blood transfusion, bruises easily, or excessive bleeding?
Please describe any medical or behavioral issues not listed above
Developmental History
Please check the following if your child is the age of (0‐3 years of age)
Check for Yes
Problems
Details
Baby born premature
Problem during pregnancy
Problems immediately after birth?
Rh or blood disorder?
Feeding problems?
Did baby go home from hospital with mother?
PLEASE COMPLETE FOR ALL CHILDREN
Questions
Age
At what age did your child stand?
At what age did your child walk?
At what age did your child talk?
Check for Yes
Problems
Details
Was your child breast fed? When stopped?
Was your child bottle fed? When stopped?
Did your child use a pacifier? When stopped?
Has your child ever sucked a finger or thumb? When stopped?
Has your child ever chewed lips or fingernails? When stopped?
Is your child adopted?
Please complete the following if your child is the age of (9‐18 years ofage)
Check for Yes
Questions
Has your child recently had a growth spurt?
Do you think your child has stopped growing?
Has your child shown any signs of reaching puberty?
(Example: Girls‐monthly menstruation,Boys-Shaving,voicechange)
Dental History
Check for Yes
Questions
Is this your child’s first visit to a dentist?
Has your child experienced tooth pain in the past year?
Is your child in pain at this time?
Has your child ever experienced trauma to teeth, mouth or face?
Does your child think anything is wrong with his/her teeth?
Has your child ever had an unfavorable dental experience?
Do you think your child will react negatively to or be upset by dental treatment?
Does your child brush his/her own teeth? How often?
Do you help your child brush?
Does your child’s gums bleed when brushing?
Does your child floss his/her teeth?
Does your child use fluoride products, rinses, drops, or tablets?
What is the main water source consumed by your child?
City water
Well water
Bottled water
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