Patient Registration: Dental And Medical Health History
ADVERTISEMENT
1
2Page 1 of 2
Justin A. Welke, DDS
Patient Registration: Dental and Medical Health History
Please complete this registration form. If you have any questions, please ask.
Patient’s Name ____________________________________________ Date of Birth _____________ Today’s Date_______________
First name
Last name
Month/Day/Year
Month/Day/Year
Dental History
Is this your child’s first dental visit?
Yes No
___________________________________________
1.
Previous Dentist’s Name
Has your child ever had problems receiving dental care?
Yes No
___________________________________________
2.
Explain Problem(s)
3.
Are you aware of any problems with your child’s teeth?
Yes No
___________________________________________
Explain Problem(s)
4.
Who brushes the child’s teeth at home?
_______________________
______________
Who Brushes?
How Often?
5.
Is the patient receiving fluoride in any form?
Yes No
___________________________________________
Type of Treatment
6.
Is there a history of trauma to the mouth/head/teeth?
Yes No
___________________________________________
Explain Problem(s)
7.
Does your child suck his/her thumb/fingers/pacifier?
Yes No
___________________________________________
Explain Problem(s)
8.
At what age did your child stop bottle feeding? _______________________ Breast feeding? ____________________________
Medical History
Physician’s/Clinic Name_________________________________________ Phone ( ______ ) _______________________________
Address ____________________________________________________________________________________________________
Street
City
State
Zip
1.
If necessary, may we consult with this physician?
Yes No
___________________________________________
Special Instructions
2.
Are your child’s vaccinations up to date?
Yes No
___________________________________________
Explain Problem(s)
3.
Please describe any health conditions that are of present concern
(medications, pending surgeries, recent injuries, issues related to healthcare)
________________________________________________________________________________________________________
4.
Is your child being treated by a physician or alternative
medicine practitioner at this time?
Yes No
___________________________________________
Please Describe
5.
Is your child taking any medicines, herbal medicines,
homeopathic and/or nutritional supplements at this time? Yes No
___________________________________________
Please list Medications, Remedies and/or Supplements
_______________________________________________________________________________________
Medications, Remedies and/or Supplements
6.
Has your child ever been admitted to a hospital?
Yes No
___________________________________________
Please Describe
7.
Has your child ever received general anesthesia/sedation? Yes No
___________________________________________
Please Describe
8.
Is your child allergic to any medicines/substances/foods? Yes No
___________________________________________
Please name allergy source
9.
Has your child ever had a blood transfusion?
Yes No
___________________________________________
Please Describe
Birth History
1.
Full term
Yes No
___________________________________________
Please Describe
2.
Low birth weight and/or other complications
Yes No
___________________________________________
Please Describe
3.
Neo-natal Illness
Yes No
___________________________________________
Please Describe
Rev 12/08
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical