Medical-Dental History Page 3
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2
3Medical History
1) Has your child had previous dental treatment?
YES
NO
If so,when? __________________________________________________________________________________________________
2) Has your child ever had an unpleasant dental experience?
YES
NO
If yes, please explain:
__________________________________________________________________________________________________
3) Have there been any injures to the teeth or mouth?
YES
NO
If yes, please explain:
__________________________________________________________________________________________________
4) Does your child have a toothache or other urgent dental problems?
___________________________________________________________________________________________________
5) Was your child referred for / or do you wish (please circle)
Consultation
Complete Treatment
Specific Problem
6) Is either parent nervous or anxious about their own dental treatment?
YES
NO
7) Has your child ever received a local anesthetic (freezing)
YES
NO
Dental Disease Prevention
3) Does your child use dental floss
YES
NO
4) Does someone assist your child with tooth cleaning
YES
NO
6) Does your child use a fluoride containing toothpaste?
YES
NO
8) Does your child eat sweets, drink soft drinks, or juice (please circle)
More than once a day
Once per week
Less that once per week
9) How does your child receive fluoride? (please circle)
Well water
Fluoride drops or tables
Fluoride gel or rinses
Not at all
10) How was your child fed as an infant? (please circle)
Breast
Bottle
I attest to the accuracy of the information provided on these 3 pages.
Parent’s Signature:________________________________
Date:_______________________
Dentist’s Signature: _______________________________
Date: _______________________
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