Medical And Dental History For Children 12 And Under
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1
2Medical and Dental History for Children 12 and Under
Patient Name
D.O.B.
Parent/Guardian’s Name ________________________________Relationship to Child___________________
Emergency Contact (Name/Phone Number) ____________________________________________________
Medical History
1. Does your child have any current health problems? .......................................................................
Yes
No
If yes, please explain ______________________________________________________________________
2. Is your child under care of a physician? ..........................................................................................
Yes
No
Name of physician ______________________________________________________________________________
3. Is your child receiving any medications? ........................................................................................
Yes
No
If so, what and when? ___________________________________________________________________________
4. Has your child had any serious illness? ...........................................................................................
Yes
No
If so, what and when? ___________________________________________________________________________
5. Has your child ever had surgery or is surgery contemplated? .......................................................
Yes
No
Explain _________________________________________________________________________________
6. Does your child have a heart murmur or any other heart condition? ...........................................
Yes
No
7. Does your child experience severe or prolonged bleeding? ..........................................................
Yes
No
Explain _______________________________________________________________________________________
8. Does your child have AIDS or has he/she tested HIV positive? ......................................................
Yes
No
9. Has your child tested positive for hepatitis? ..................................................................................
Yes
No
10.
Has your child had a history of nervous disorders?
...........................................................................................
Yes
No
11.
Does your child have frequent headaches?
..............................................................................................
Yes
No
Explain
_______________________________________________________________________________________
12. Is your child allergic/sensitive to:
None
Codeine
Penicillin
Local Anesthetic
Latex
Pine Nuts
Dyes
Other
_______________________________________________________________________________________
13.
Has your child had history of:
Yes
No
Yes
No
Diabetes ..................................................
Cerebral palsy .........................................
Yes
No
Yes
No
Asthma ...................................................
Cancer ....................................................
Yes
No
Yes
No
Hay fever ................................................
Leukemia ................................................
Kidney infection .....................................
Yes
No
Oral Herpetic Lesion ..............................
Yes
No
Yes
No
Yes
No
Liver problems ........................................
Eating Disorders .....................................
Yes
No
Yes
No
Hepatitis/ Jaundice .................................
Speech impairments ................................
Yes
No
Yes
No
Thyroid Problems ...................................
Hearing Impaired ...................................
Yes
No
Yes
No
Rheumatic fever ......................................
Take pre-medication for anything ...........
Epilepsy/ Seizures/ Fainting .....................
Yes
No
If yes, what for ______________________________
102503_2878017-00100_CP_85X11SPLIT55FB_J.indd 1
102503_2971211-00500_CP_85x11-CTR_J CHLD MED HX 211 - black.indd 1
12/22/2014 4:40:58 PM
4/2/2015 1:29:31 PM
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Parent category: Medical