Patient Information And Medical History

ADVERTISEMENT

Patient Information
and Medical History
PATIENT NAME: ________________________________________________________ DATE OF BIRTH:__________________
MALE
FEMALE
NAME CHILD GOES BY:_________________________________________________
HOME PHONE:___________________________________________
ADDRESS:_________________________________________________________________________________________
ZIP CODE:____________________
NAMES & AGES OF OTHER CHILDREN:______________________________________________________________________________________________
FATHER’S NAME:_____________________________________________________
BUSINESS PHONE:_________________________________________
EMPLOYER:___________________________________________________________________
OCCUPATION:_____________________________________
MOTHER’S NAME:____________________________________________________
BUSINESS PHONE:_________________________________________
EMPLOYER:___________________________________________________________________
OCCUPATION:_____________________________________
MARITAL STATUS OF PARENTS:
SINGLE
MARRIED
WIDOWED
SEPARATED
DIVORCED
PARTNERED
PARENT’S DENTIST:__________________________________________
CHILD’S PEDIATRICIAN:____________________________________________
CHILD’S SCHOOL:____________________________________________
WHOM MAY WE THANK FOR
REFERRING YOU TO OUR OFFICE?:_________________________________
HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING CONDITIONS? IF YES, PLEASE CHECK BOX.
ADD/ADHD
DIABETES
RESPIRATORY PROBLEM
ANEMIA
EPILEPSY / SEIZURES
RHEUMATIC FEVER
ASTHMA
GASTRIC REFLUX
SINUS PROBLEM
AUTISM
HEART DISEASE OR ARRHYTHMIA
STOMACH PROBLEM
BEHAVIORAL DISORDER
HEART MURMUR
PENICILLIN ALLERGY
BLOOD DISEASE
HEMOPHILIA / BLEEDING DISORDER
LATEX ALLERGY
BONE DISORDER
KIDNEY OR LIVER DISEASE
OTHER ALLERGY:
________________________________
DEVELOPMENTAL DELAY
PHYSICAL DISABILITY
OTHER MEDICAL CONDITION:
________________________________
@IS YOUR CHILD UNDER THE CARE OF A PHYSICIAN FOR OTHER THAN ROUTINE CARE? IF YES, PLEASE EXPLAIN:
_____________________________________________________________________________________________________________________________________
@PLEASE LIST ALL MEDICATIONS THAT YOUR CHILD IS TAKING AT THIS TIME:
_____________________________________________________________________________________________________________________________________
@HAS YOUR CHILD HAD AN UNFAVORABLE DENTAL EXPERIENCE? IF YES, PLEASE EXPLAIN:
_____________________________________________________________________________________________________________________________________
@DOES YOUR CHILD HAVE A HISTORY OF
THUMBSUCKING,
FINGERSUCKING, OR
PACIFIER USE? IF YES, PLEASE CHECK BOX.
@DATE OF CHILD’S LAST DENTAL VISIT:_______________________________________
The above information is true and correct to the best of my knowledge.
I agree to inform this office immediately of any changes in my child’s medical status.
________________________________________________________________________
______________________
Signature of Parent or Legal Guardian
Date
Eaton Pediatric Dentistry, P.C.
3744-A Lavista Road @Decatur, Georgia @30033
0511

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Information And Medical History Form Patient Information And Medical History Form Medical
Patient Registration And Medical History Form Patient Registration And Medical History Form Medical
Patient Registration And Medical History Form - Glacier Valley Endodontics Patient Registration And Medical History Form - Glacier Valley Endodontics Medical
Patient Ocular And Medical History Form Patient Ocular And Medical History Form Medical
New Patient Registration And Medical History Sheet New Patient Registration And Medical History Sheet Medical
Pediatric Dentistry Of North Texas Patient Information And Health History Form Pediatric Dentistry Of North Texas Patient Information And Health History Form Medical
Patient Information And History Form Patient Information And History Form Medical
Patient Information-family Medical Center Form Patient Information-family Medical Center Form Medical
Patient Registration And Health History Form Patient Registration And Health History Form Business
Patient Registration And Health History Form Patient Registration And Health History Form Medical

Related Categories

Parent category: Medical
Download
Go