Pediatric Medical History - American Academy Of Pediatric Dentistry Page 2
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3AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
What is your primary concern about your child’s oral health? ________________________________________________________________________
How would you describe:
your child’s oral health?
q Excellent
q Good
q Fair
q Poor
your oral health?
q Excellent
q Good
q Fair
q Poor
the oral health of your other children?
q Excellent
q Good
q Fair
q Poor
q Not applicable
Is there a family history of cavities?
q YES
q NO
If yes, indicate all that apply: q Mother q Father q Brother
q Sister
Does your child have a history of any of the following? For each YES response, please describe:
______________________________________________________________________
Inherited dental characteristics
q YES q NO
______________________________________________________________________
Mouth sores or fever blisters
q YES
q NO
______________________________________________________________________
Bad breath
q YES q NO
______________________________________________________________________
Bleeding gums
q YES
q NO
______________________________________________________________________
Cavities/decayed teeth
q YES q NO
______________________________________________________________________
Toothache
q YES q NO
______________________________________________________________________
Injury to teeth, mouth or jaws
q YES q NO
______________________________________________________________________
Clinching/grinding his/her teeth
q YES
q NO
______________________________________________________________________
Jaw joint problems (popping, etc.)
q YES q NO
______________________________________________________________________
Excessive gagging
q YES q NO
Sucking habit after one year of age
q YES q NO
If yes, which: q Finger q Thumb q Pacifier q Other q For how long? __________
How often does your child brush his/her teeth? ________ times per ___________
Does someone help your child brush?
q YES q NO
How often does your child floss his/her teeth?
q Never
q Occasionally
q Daily
Does someone help your child floss?
q YES q NO
What type of toothbrush does your child use?
q Hard
q Medium
q Soft
q Unsure
What toothpaste does your child use? _______________________________________________
What is the source of your drinking water at home?
q City/community supply
q Private well
q Bottled water
Do you use a water filter at home?
q YES
q NO
If YES, type of filtering system: _______________________
Please check all sources of fluoride your child receives:
q Drinking water
q Toothpaste
q Over-the-counter rinse
q Prescription rinse/gel
q Prescription drops/tablets/vitamins
q Fluoride treatment in the dental office
q Fluoride varnish by pediatrician/other practitioner
q Other: ______________________
Does your child regularly eat 3 meals each day?
q YES
q NO
Is your child on a special or restricted diet?
q YES
q NO
If YES, describe: _________________________________
Is your child a ‘picky eater’?
q YES
q NO
If YES, describe: _________________________________
Does your child have a diet high in sugars or starches?
q YES
q NO
If YES, describe: _________________________________
Do you have any concerns regarding your child’s weight?
q YES
q NO
If YES, describe: _________________________________
How frequently does your child have the following?
Product ____________________
Candy or other sweets
q Rarely
q 1-2 times/day
q 3 or more times/day
Type ______________________
Chewing gum
q Rarely
q 1-2 times/day
q 3 or more times/day
Snacks between meals
q Rarely
q 1-2 times/day
q 3 or more times/day
Usual snack _________________
Soft drinks*
q Rarely
q 1-2 times/day
q 3 or more times/day
Product ____________________
(* such as juice, fruit-flavored drinks, sodas, colas, carbonated beverages, sweetened beverages, sports drinks, or energy drinks)
Please note other significant dietary habits: ______________________________________________________________________________________
Does your child participate in any sports or similar activities?
q YES
q NO
If YES, list: _____________________________________
Does your child wear a mouthguard during these activities?
q YES
q NO
If YES, type: ____________________________________
Has your child been examined or treated by another dentist?
q YES
q NO
If YES: Date of first visit: ______________
Date of last visit: _____________
Reason for last visit: _______________________________
Were x-rays taken of the teeth or jaws?
q YES
q NO
Date of most recent dental x-rays: ____________________
Has your child ever had orthodontic treatment (braces, spacers, or other appliances)? q YES q NO
If YES, when? ________________________
Has your child ever had a difficult dental appointment? q YES
q NO
If YES, describe: __________________________________
How do you expect your child will respond to dental treatment?
q Very well
q Fairly well
q Somewhat poorly
q Very poorly
Is there anything else we should know before treating your child?
q YES
q NO
If yes, describe: ____________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_____________________________________
______________________
______________
___________________________________
Signature of parent/guardian
Relationship to child
Date
Signature of staff member reviewing history
MEDICAL / DENTAL HISTORY UPDATE
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 had any illness, surgery, injury, allergic reaction, or medical emergency in the past year? ………..................………….
q YES q NO
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
Have there recently been any significant changes/disruptions to your child’s family, home, or school routines? ……………................
q YES q NO
Describe: __________________________________________________________________________________________
What is your primary concern regarding your child’s oral health? _____________________________________________________
Has your child had any tooth pain or injury to the mouth/teeth/jaws since last visiting our office? ………………...............................
q YES q NO
Describe: __________________________________________________________________________________________
Has your child’s diet changed significantly since his/her last dental visit? Describe: _______________________________________
q YES q NO
Has your child been treated by another dentist/dental professional since last visiting our office? Reason: ______________________
q YES q NO
Is there any other change in the child’s medical, dental, or family history that the dentist should be told? ............................................
q YES q NO
Describe: ___________________________________________________________________________________________
_____________________________________
_________________
_____________
___________________________________
Signature of parent/guardian
Relationship to child
Date
Signature of staff member reviewing history
RESOURCE SECTION
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