Child'S Dental/medical History
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1Child’s Dental/Medical History
Patient Name _____________________________________________
Date of Birth ____________________________
Dental History
What is the reason for today’s visit? ___________________________________________________________________________
Is this the child’s first visit to a dentist?
Yes
No If no, when was the last dental visit?_______________
Former dentist, if any? _____________________________ ___________________ Phone ________________________________
Has the child ever had any dental X-rays?
Yes
No
Has your child ever had any injuries to the mouth, head or teeth? ________________________
Has your child ever had any problem with dental treatment in the past? ___________________
Has your child ever had any orthodontic treatment? ___________________________________
What type of water does your child drink?
City water
Well water
Bottled water
Filtered water
Has your child ever received fluoride supplements?
Yes
No If yes, what age? __________________________
How many times are the child’s teeth brushed per day? ________ When? _______________________________________
Has the child sucked his or her thumb, fingers, or pacifier?
Yes
No Does the habit still exist? _________
Does the child grind his or her teeth?
Yes
No
Medical History
1.) Is your child taking any prescription and/ or over the counter medications?
No
Yes
If yes, please list _________________________________________________________________
2.) Is your child allergic to any medications?
No
Yes
If yes, please list _________________________________________________________________
3.) Is your child allergic to any foods or materials?
No
Yes
If yes, please list _________________________________________________________________
4.) Has your child been hospitalized?
No
Yes
When? __________________________________ Reason? ______________________________
Has your child had any history or ever been diagnosed with any of the following:
Anemia
Bleeding Disorder
Eye problems
Measles
Bone/ joint/ orthopedic
Fainting
Mumps
Allergy/ Hay Fever
problem
Growth problem
Nervous disorders
Artificial heart valve
Brain injury
Hearing loss/ aids
Pneumonia
Artificial joint/ limb
Cancer, type _____________
Heart murmur
Rheumatic Fever
Asthma
Cerebral Palsy
Heart problem
Scarlet Fever
Attention Deficit
Chemotherapy
Heart surgery
Shunt
Disorder
Chicken Pox
Hepatitis
Sickle cell anemia
Autism
Chronic sinusitis
HIV+ / AIDS
Tetanus
Behavior/ learning
Cleft lip/ palate
Hormonal disturbances
Tuberculosis
disabilities
Diabetes
Kidney problems
Other:
Epilepsy/ seizure
Digestive disturbances
Liver problems
______________________________
______________________________
Birth defects
Pediatrician/ Physician Name ___________________________________________________ Phone _____________________
I understand that the above information will be used for my child’s dental health. I have answered the questions
to the best of my ability. If further information is needed you may contact my child’s health care physician for
any other information.
Parent Signature___________________________________________________________________ Date________________________
Doctor’s initials_____________
Alliance Dentistry NC Child Medical History
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