Patient Registration: Dental And Medical Health History Page 2
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Patient’s Name ____________________________________________ Date of Birth _____________ Today’s Date_______________
First name
Last name
Month/Day/Year
Month/Day/Year
Medical History (continued)
Please review the following groups of questions. Indicate if there is a current health problem, or if there was a problem in the past for your child.
Blood, Heart and Liver Organ Systems
Muscles and Nervous System
Anemia
Yes
No
_________________
Cerebral Palsy
Yes
No
_________________
Hemophilia
Yes
No
_________________
Convulsions/Seizures
Yes
No
_________________
Sickle Cell Anemia
Yes
No
_________________
Epilepsy
Yes
No
_________________
Heart Problems
Yes
No
_________________
Spina Bifida
Yes
No
_________________
Hepatitis
Yes
No
_________________
Other _____________________________________________
HIV/AIDS
Yes
No
_________________
Bones
Rheumatic Fever
Yes
No
_________________
Orthopedic Problems
Yes
No
_________________
Leukemia
Yes
No
_________________
Rickets
Yes
No
_________________
Other _____________________________________________
Scoliosis
Yes
No
_________________
Eyes, Ears, Nose, Throat and Pulmonary System
Other _____________________________________________
Eye Problems
Yes
No
_________________
Psychological and Emotional
Hearing Problems
Yes
No
_________________
Clinical Depression
Yes
No
_________________
Frequent Ear Infection
Yes
No
_________________
ADD/ADHD
Yes
No
_________________
Asthma
Yes
No
_________________
Autism
Yes
No
_________________
Mouth Breathing
Yes
No
_________________
Brain Injury
Yes
No
_________________
Frequent Sore Throat
Yes
No
_________________
Cognitive Impairment
Yes
No
_________________
Sinus Problems
Yes
No
_________________
Behavioral Issues
Yes
No
_________________
Snoring at Night
Yes
No
_________________
Other _____________________________________________
Cleft Lip/Palate
Yes
No
_________________
Tuberculosis
Yes
No
_________________
Childhood Disease History
Bronchitis
Yes
No
_________________
Chicken Pox
Yes
No
_________________
Pneumonia
Yes
No
_________________
Measles
Yes
No
_________________
Other _____________________________________________
Mumps
Yes
No
_________________
Other _____________________________________________
Kidney and Bladder
Renal Disease
Yes
No
_________________
Adolescent Social Issues that can Affect Dental Health
Frequent Infections
Yes
No
_________________
Pierced Lips/Tongue
Yes
No
_________________
Other _____________________________________________
Smoking
Yes
No
_________________
Alcohol
Yes
No
_________________
Endocrine and Glands
Eating Disorders
Yes
No
_________________
Diabetes
Yes
No
_________________
Substance Abuse
Yes
No
_________________
Thyroid Problems
Yes
No
_________________
Oral Infections
Yes
No
_________________
Other _____________________________________________
Pregnancy
Yes
No
_________________
Other _____________________________________________
Consent to Treatment
The undersigned hereby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a
thorough diagnosis of my child’s dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication, and therapy that
may be indicated for my child. I understand the use of anesthetic agents embodies a certain risk. I have had the opportunity to ask questions and
understand the benefits/risks of the proposed treatment for my child.
Signature ______________________________ ________________ Date: _____________ Dentist signature _________________
Parent/Guardian
Relationship to Child
Rev 12/08
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