Pediatric Medical History - American Academy Of Pediatric Dentistry

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REFERENCE MANUAL
V 37
NO 6
15
16
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Pediatric Medical History
Child’s Full Name: _____________________________________________
Nickname: ___________________
Date of birth: ____/____/______
Gender: q M q F
Race/Ethnicity: _________________
Height: _____ Weight: _______
Date of last physical examination: ___________
Name/address/phone of primary physician: _____________________________________________________________________________________
Name/address/phone of medical specialists: _____________________________________________________________________________________
Is your child being treated by a physician at this time? Reason ___________________________________________________
q YES q NO
Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements? ………………........…
q YES q NO
List name, dose, frequency & date started: ______________________________________________________________
Has your child ever been hospitalized, had surgery or a significant injury, or been treated in an emergency department? ..........…
q YES q NO
List date & describe: _______________________________________________________________________________
Has your child ever had a reaction to or problem with an anesthetic? Describe ______________________________________
q YES q NO
Has your child ever had a reaction or allergy to an antibiotic, sedative, or other medication? List ________________________
q YES q NO
Is your child allergic to latex or anything else such as metals, acrylic, or dye? List ____________________________________
q YES q NO
Is your child up to date on immunizations against childhood diseases? .........................................................................................
q YES q NO
Please mark YES if your child has a history of the following conditions. For each “YES”, provide details in the box at the bottom of this list. Mark NO after each line if none
of those conditions applies to your child.
Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions ……..……………......
q YES q NO
Problems with physical growth or development ………………...……..………...………………………………………......
q YES q NO
Sinusitis, chronic adenoid/tonsil infections ……………………………………………………………….............................
q YES q NO
Sleep apnea/snoring, mouth breathing, or excessive gagging ……………………..……………………………………….....
q YES q NO
Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease …………………………….......
q YES q NO
Irregular heart beat or high blood pressure ……………………………………………………………………………..........
q YES q NO
Asthma, reactive airway disease, wheezing, or breathing problems ………………..……………..………………………......
q YES q NO
Cystic fibrosis ………………………………………………………………………………………………………….........
q YES q NO
Frequent colds or coughs, or pneumonia …….………………………………………………...……………………............
q YES q NO
Frequent exposure to tobacco smoke ............................................……………………………………………………..........
q YES q NO
Jaundice, hepatitis, or liver problems …………………………………………………………………………………..........
q YES q NO
Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems ……………..…………………….......
q YES q NO
Lactose intolerance, food allergies, nutritional deficiencies, or dietary restrictions ……………………………………….......
q YES q NO
Prolonged diarrhea, unintentional weight loss, concerns with weight, or eating disorder …………..……………………......
q YES q NO
Bladder or kidney problems ……………………………………..…………………………………………………..….......
q YES q NO
Arthritis, scoliosis, limited use of arms or legs, or muscle/bone/joint problems ………………………………………..….....
q YES q NO
Rash/hives, eczema or skin problems …………………………………………………………………………………..........
q YES q NO
Impaired vision, hearing, or speech …………………………….………………………………………………..….............
q YES q NO
Developmental disorders, learning problems/delays, or intellectual disability …………………….…..…………………......
q YES q NO
Cerebral palsy, brain injury, epilepsy, or convulsions/seizures ……………………………………………..……………........
q YES q NO
Autism/autism spectrum disorder ……………………………………………………………………………...………........
q YES q NO
Recurrent or frequent headaches/migraines, fainting, or dizziness …………………………………………..………….........
q YES q NO
Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous) ……………..…...……......
q YES q NO
Attention deficit/hyperactivity disorder (ADD/ADHD) ……………………………………………………………….........
q YES q NO
Behavioral, emotional, communication, or psychiatric problems/treatment ……………………………………………........
q YES q NO
Abuse (physical, psychological, emotional, or sexual) or neglect ……………………………………………………….........
q YES q NO
Diabetes, hyperglycemia, or hypoglycemia …………………………………………………………………………….........
q YES q NO
Precocious puberty or hormonal problems ……………………………………………………………………………….....
q YES q NO
Thyroid or pituitary problems …………………………………………………………………………………………........
q YES q NO
Anemia, sickle cell disease/trait, or blood disorder ………………………………………………………………………......
q YES q NO
Hemophilia, bruising easily, or excessive bleeding ………………………………………………………………………......
q YES q NO
Transfusions or receiving blood products ……………………………………………………………………………...........
q YES q NO
Cancer, tumor, other malignancy, chemotherapy, radiation therapy, or bone marrow or organ transplant ……………..........
q YES q NO
Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), methicillin resistant staphylococcus aureus (MRSA),
sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS .…..………......................................
q YES q NO
PROVIDE DETAILS HERE: _______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Is there any other significant medical history pertaining to this child or his/her family that the dentist should be told? ...............
q YES q NO
If YES, describe _______________________________________________________________________________________________________
____________________________________________________________________________________________________________________

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