Child Patient And Responsible Party Information Form Page 2
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3Medical History
Patient’s Family Dentist
Phone # ____________________________
Address_______________________________________________________________________________________
Patient’s Family Physician___________________________________ Phone # ____________________________
Address ______________________________________________________________________________________
Emergency Contact (person to contact in case of an emergency)
Name ________________________________ Phone #_______________________ Relation___________________
Does responsible party have Orthodontic Insurance? Yes No
MEDICAL HISTORY:
Excellent
Good
Fair
Poor
Patient’s general health:
Last complete physical:
Date ___/___/___
Has patient had or does patient have any of the following?
Yes
No
Yes
No
Rheumatic Fever
Persistent Headaches
Heart Murmur
Neck Pains
High Blood Pressure
Nerve or Brain Disease
Heart Attack/Stroke
Migraine
Blood Vessel Disease
Epilepsy
Blood Disorder
Mental Health Problems
AIDS/HIV Infection
Bone Disorders
Hepatitis
Arthritis (any type)
Diabetes
Sleep Apnea
Ulcers
Ear Disorder
Herpes (any type)
Sinus Infection
Psoriasis
Swollen Glands
Cancer
Allergies
Comments
Please list any other significant information about the patient’s medical history:
Yes
No
Is patient under a physician’s care at present? If yes, reason
Is patient presently, or has patient ever been under the care of a psychiatrist or
Psychologist? If yes, describe
Is patient currently taking any medication? If yes, describe
Is the patient allergic to any medications? (Ex.: aspirin, penicillin, etc.) If yes, what?
Has patient ever had any general anesthesia? When?
Does patient need to Pre-Medicate?
If patient is female, has menstrual cycle started?
Please describe why you sought this consultation________________________________________________
Has patient ever been treated for this problem before? If yes, please describe the diagnosis and treatment
__________________________________
DENTAL HISTORY
Last dental check-up:
Dr.
Date _____/_____/______
Bleeding Yes No
How often are the teeth brushed daily:
Flossed
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Parent category: Medical