Medical History Form

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Medical History Form
I.
GENERAL INFORMATION
Residence address:___________________________________________________________Phone: ____________________________________
City:_____________________________________________________State:_________________Zip code: _______________________________
Father:___________________________________________Birthdate:_______________Social security #: _____________________________
Employed by:_________________________________________________Phone number: __________________________________________
Cell phone number:________________________________Email address: ______________________________________________________
Mother:__________________________________________Birthdate:_______________Social security #: _____________________________
Employed by:_________________________________________________Phone number:______________________________
Cell phone number:________________________________Email address: ______________________________________________________
Child’s Name (first, last):_________________________________________________Nickname ___________________________________
Age:___________Birthdate:___________________________________Place of Birth:__________________________________Gender M / F
Names & Ages of Siblings: ______________________________________________________________________________________________
Attends what school:______________________________________________ Referred by: _________________________________________
II.
MEDICAL HISTORY (circle appropriate condition)
1.
Has your child ever experienced any of the following:
A.
Cerebral palsy, seizures, convulsions, fainting, loss of consciousness, trauma to head, recurrent headaches ...................... Yes......... No
B.
Sensory disorders of seeing or hearing ...................................................................................................................................................... Yes......... No
C.
Behavioral, learning, or communication problems, excessive nervousness ................................................................................... Yes......... No
D.
Congenital heart disease, heart murmur, heart damage from rheumatic fever ....................................................................... Yes......... No
E.
History of chest pains or high blood pressure ......................................................................................................................................... Yes......... No
F.
Prolonged bleeding, blood dyscrasias or diseases, blood transfusions or HIV infection ............................................................. Yes......... No
G.
Cystic fibrosis, pneumonia, asthma, shortness of breath, difficulty breathing .............................................................................. Yes......... No
H.
Stomach, liver, intestinal problems, hepatitis, jaundice ...................................................................................................................... Yes......... No
I.
Pregnancy or possible pregnancy, kidney or bladder disease .......................................................................................................... Yes......... No
J.
Diabetes, thyroid disease, or other glandular problems ..................................................................................................................... Yes......... No
K.
Limitations of arms or legs, joint replacement, or muscular dystrophy ......................................................................................... Yes......... No
2.
Has your child ever experienced the following:
A.
Allergy to any medication?__________
If so, what medication and what was the reaction? __________________________________________________________________
B.
Allergy or sensitivity to other materials or chemicals, such as LATEX, NUTS, DYES etc.? ______________________________________
If so, which material and what was the reaction? ____________________________________________________________________
3.
Is your child currently on any medication?__________
If yes, please list ________________________________________________________________________________________________________
4.
Does your child have any other medical condition or syndrome, not reflected in the above questions? __________
If yes, please list ________________________________________________________________________________________________________
5.
Has your child ever been hospitalized?_________
If yes, for what?__________________________________________________________________________________________________
6.
Child’s physician or pediatrician_____________________________________________________________________________________
Address____________________________________________________________________Phone_______________________________
7.
Date of last medical exam_________________________________________________________________________________________
III. DENTAL HISTORY
1.
Is this your child’s first visit to a dentist? ___________________________________________________________________________________________
2.
Who is your family dentist? ______________________________________________________________________________________________________
3.
Has your child had a toothache recently? _________________________________________________________________________________________
4.
Has your child ever injured their mouth, teeth, or jaw? _____________________________________________________________________________
5.
Does (or has) your child have (or had) a sucking habit beyond one year of age?______________
If yes, check: Thumb______Finger_____Pacifier______Other_______
6.
Does (or has) your child have (or had) any other oral habits?_________________
If yes, check: Nail biting_______Teeth grinding________Other______
7.
Does your child have a history of any TMJ clicking or popping? _____________________________________________________________________
IV. DENTAL DISEASE PROBLEMS
1.
How often are your child’s teeth brushed?___________times per_________
2.
Does your child use dental floss?___________________________________
3.
Does your child use fluoride toothpaste?_____________________________
4.
What is your child’s drinking water source?
City_______Well_____Other_________
5.
Does your child drink fruit juice or soda pop?_________
If so, how many ounces per day?___________________
___________initials

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