Patient Medical And Dental History Form

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MEDICAL-DENTAL HISTORY
DATE: ___________________________________
Circle One
Child’s Name:
____________________________________ M / F Birthdate: _____________ Age: _____ SSN: _________________
Address: ________________________________________________ City, State, Zip: _______________________________________
Phone: ____________________________________ School: _______________________________________ Grade: _____________
Father’s Name: __________________________ SSN: ______________ Birthdate: ___________ Employer: ____________________
Mother’s Name: _________________________ SSN: ______________ Birthdate: ___________ Employer: ____________________
Father’s Business Phone: _________________________________ Mother’s Business Phone: _______________________________
Father’s Cell Phone: _____________________________________ Mother’s Cell Phone: ____________________________________
Name of Dental Insurance: ________________________________ / ____________________________________________________
Name of Medical Insurance: _______________________________ / ___________________________________________________
MEDICAL HISTORY
Preferred Email:
________________________________________________
GROWTH AND DEVELOPMENT Any Learning, Behavior, Anxiety, or Speech issues?
No ( )
Yes ( )
If Yes, List: _______________________________________________________________________
Has the child had Psychological Counseling or is counseling being considered?
No ( )
Yes ( )
Any Complications during Pregnancy or Prematurity at Birth?
No ( )
Yes ( )
Are there any Problems with Physical Growth?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
CENTRAL NERVOUS SYSTEM Any history of Cerebral Palsy? Seizures? Convulsions?
No ( )
Yes ( )
Any history of Head Injury? Concussion? Loss of Consciousness? Fainting?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
CARDIOVASCULAR SYSTEM Any history of Congenital Heart Disease? Heart Murmur? Heart Damage?
No ( )
Yes ( )
Does your child have to take Preventative Antibiotics for any heart condition or shunt prior to dental care?
No ( )
Yes ( )
Any history of Heart Surgery or recommendations for Heart Surgery?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
HEMATOPOIETIC AND LYMPHATIC SYSTEMS Any history of Blood Transfusion?
No ( )
Yes ( )
Any history of Anemia? Sickle Cell Disease? Sickle Cell Trait?
No ( )
Yes ( )
Does your child Bruise Easily? Have Frequent Nosebleeds? Bleed Excessively from Small Cuts?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
RESPIRATORY SYSTEM Any history of Asthma? If Yes, Causes: ________________________________________________
No ( )
Yes ( )
Any history of Cystic Fibrosis? Pneumonia? Shortness of Breath? Difficulty in Breathing?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
GASTROINTESTINAL SYSTEM Any history of Stomach, Intestinal, or Liver Problems?
No ( )
Yes ( )
Any history of Hepatitis? Jaundice?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
GENITOURINARY SYSTEM Any history of Urinary Tract Infections? Bladder Problems? Kidney Problems?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
ENDOCRINE SYSTEM Any history of Diabetes? If Yes, Type: ____________________________
No ( )
Yes ( )
Any history of Thyroid Disorders? Other Glandular Disorders?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
SKIN Any history of Eczema? Other Skin Problems?
No ( )
Yes ( )
Any history of Cold Sores? Canker Sores? If Yes, Frequency: _____________________________
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
EXTREMITIES Any Limitations of the Use of Arms or Legs?
No ( )
Yes ( )
Any history of Arthritis? Other Joint Problems?
No ( )
Yes ( )
Any Problems with Muscle Weakness? Muscular Dystrophy?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
ALLERGIES Is your child Allergic to any Medications? If Yes, List: ________________________________________________
No ( )
Yes ( )
Is your child Allergic to Anything Else? If Yes, List: _____________________________________________________
No ( )
Yes ( )
Any history Seasonal Allergies? Hay Fever? Hives? Skin Rashes caused by Allergies?
No ( )
Yes ( )
Any history of ANAPHYLATIC Reaction to any Medication or Other Allergen?
No ( )
Yes ( )
__________________________________________________________________________________________________________________________________________________________
MEDICATIONS Is your child currently taking any medication (prescription or non-prescription)?
No ( )
Yes ( )
If Yes, List Medication(s):
Reason:
Dosage/Frequency:
_______________________________________________ ___________________________ __________________________________
_______________________________________________ ___________________________ __________________________________
_______________________________________________ ___________________________ __________________________________
_______________________________________________ ___________________________ __________________________________

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