Medical History
* - Indicates a required field
Dental / Medical History
*
Name
Has your child been to the dentist before?
Yes
No
If yes, the approximate date of last visit:
Are there any dental problems that you are aware of at present?
Yes
No
If yes, please explain
Does your child brush his / her teeth daily?
Yes
No
Please rate your chid´s oral health
Good
Fair
Poor
Is your child currently under the care of a physician?
Yes
No
Child´s physician
His / Her phone #
The aproximate date of last visit
Please rate your child´s medical health
Good
Fair
Poor
Is your child allergic to any drugs or other things?
Yes
No
If yes, please list
Is your child taking any prescription drugs?
Yes
No
If yes, please list
Does your child require antibiotics before dental treatment
Yes
No
Has your child ever had any of the following medical conditions or problems?
Any Hospital Stays
Yes
No
Any Operations
Yes
No
Bleeding Problems of Any Kind
Yes
No
Cancer
Yes
No
Convulsions / Epilepsy
Yes
No
Diabetes
Yes
No
Hearing Impairment
Yes
No
Heart Murmur
Yes
No
Heart Problems of Any Kind
Yes
No
Hemophilia
Yes
No
HIV+ / AIDS
Yes
No
Hyperactive
Yes
No
Rheumatic / Scarlet Fever
Yes
No
Are there any other medical conditions or problems relating to child?
Yes
No
If yes, please list
In the event of any emergency, whom should we contact?
Name
Relationship
Phone
Phone #2
Understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsability to inform this office of any changes in my child´s medical status. I authorize the dental staff to perform the necessary dental services my child may need.
IMPORTANT: Please confirm the following to validate this registration:
By selecting this check box, you are confirming that you have filled out the above form to your best knowledge.
Children Registration
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Children Medical History
