Pediatric Medical History - American Academy Of Pediatric Dentistry Page 3
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3REFERENCE MANUAL
V 37
NO 6
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SUPPLEMENTAL HISTORY QUESTIONS FOR AN INFANT
TODDLER:
/
Was your child born prematurely?
If YES, what week? _________________
q YES
q NO
What was your child’s birth weight? _________________________
How long was your child breast-fed?
q N/A
q less than
q 6-11
q 12-17
q 18-23
q 2 years or
6 months
months
months
months
more
How long was your child bottle-fed?
q N/A
q less than
q 6-11
q 12-17
q 18-23
q 2 years or
6 months
months
months
months
more
Do/did you feed your child infant formula?
q YES
q NO
If YES, what type? (check one): q Ready to use
q Powdered
q Liquid concentrate
Does/did your child sleep with a bottle?
If YES, content of bottle? ________________________________
q YES
q NO
Does/did your child use a no-spill training cup
q YES
q NO
(sippy cup)?
Child’s age (in months) when first tooth appeared in mouth ____________________
Has your child experienced any teething problems?
q YES
q NO
When did you begin brushing his/her teeth?
q N/A
q before age
q 6-11
q 12-17
q 18-23
q 2 years or
6 months
months
months
months
more
When did you begin using toothpaste?
q N/A
q before age
q 6-11
q 12-17
q 18-23
q 2 years or
months
months
months
more
6 months
Who is your child’s primary care taker during the day? __________________
during the evening? ___________________
Name/age of siblings at home: ______________________________________________________________________________________________
______________________________________________________________________________________________________________________
_____________________________
_____________________________
___________
__________________________________
Signature of parent/guardian
Relationship to child
Date
Signature of staff member reviewing history
SUPPLEMENTAL HISTORY QUESTIONS FOR AN ADOLESCENT PATIENT (to be completed by the patient):
Do you have any concerns about your mouth, teeth,
If YES, describe: _______________________________
q YES
q NO
or oral health?
Have you recently experienced any dental/oral pain?
If YES, describe: _______________________________
q YES
q NO
Do you have any concerns with the appearance of your
If YES, describe: _______________________________
q YES
q NO
teeth or smile?
Do you bleach your teeth?
q YES
q NO
If YES, how often: ______________________________
Have there been any recent changes in your dietary
q YES
q NO
If YES, describe: _______________________________
habits?
Are you taking any dietary or herbal supplements?
If YES, describe: _______________________________
q YES
q NO
Do you participate in contact sports or high speed
If YES, describe: _______________________________
q YES
q NO
sports (skiing, motorcycles)?
We recognize that patients may engage in certain behaviors/activities that can have significant consequences on their oral health and/or general health.
In addition, medicines that we use to treat oral conditions may interact with drugs (prescription, over-the-counter, or recreational) and other substances a
patient might be using. Therefore, we encourage our adolescent patients to answer all of the following questions truthfully. If you prefer not to answer an
item, we hope you will discuss any concerns confidentially with your dentist.
Do you have any history of:
Oral habits (chewing fingernails, clenching/grinding teeth, etc.)
q YES
q NO
q PREFER NOT TO ANSWER
Tobacco use (cigarette, pipe, cigar, bidi, snuff, spit, chew, etc.)
q YES
q NO
q PREFER NOT TO ANSWER
Eating disorder (anorexia, bulimia, etc.)
q YES
q NO
q PREFER NOT TO ANSWER
Oral piercings/jewelry (including grill)
q YES
q NO
q PREFER NOT TO ANSWER
Alcohol or recreational drug use/prescription abuse
q YES
q NO
q PREFER NOT TO ANSWER
Inhalant use/abuse (such as huffing)
q YES
q NO
q PREFER NOT TO ANSWER
Sexual activity (including oral sex)
q YES
q NO
q PREFER NOT TO ANSWER
Females: Are you pregnant or possibly pregnant?
q YES
q NO
Is there anything you would like to discuss confidentially with your dentist?
q YES
q NO
Would you like to discuss a referral to a family dentist or general dentist because of your age?
q YES
q NO
__________________________________
_______________
________________________________________________
Signature of patient
Date
Signature of staff member reviewing history
394
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