Patient Information And Medical History Form Page 2
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2FLUORIDE HISTORY
□ Yes □ No
Is your home water supply fluoridated?
□ Yes □ No
Does your child use a fluoride toothpaste?
□ Yes □ No
Do you give your child any other forms of fluoride? What? _____________________________________
□ Yes □ No
Does your child participate in a school fluoride rinse program? ___________
MEDICAL HISTORY
□ Yes □ No
Is your child in good health? Date of last physical exam _______________________________________
□ Yes □ No
Does your child have a health problem? ____________________________________________________
□ Yes □ No
Allergies (Please List) __________________________________________________________________
□ Yes □ No
Is your child taking any medications at this time? Please give medication, dose, and reason: ___________
_____________________________________________________________________________________
□ Yes □ No
Are your child's immunizations current?
□ Yes □ No
Have you ever been told that your child needs to take antibiotics before dental treatment?
□ Yes □ No
Has your child ever been hospitalized, had general anesthesia, or emergency room visits? Please explain:
_____________________________________________________________________________________
□ Yes □ No
Were there any difficulties at birth? ________________________________________________________
Do you consider your child to be: □ advanced in learning
□ progressing normally
□ slow learner
Please check if your child has been treated for any of the following:
□ Heart disease
□ Heart murmur
□ Bleeding/transfusions
□ Asthma/breathing
□ Anemia
□ Blood dyscrasias
□ Tonsil/adenoid problems
□ Tuberculosis
□ Liver/GI disease
□ Sickle cell disease/trait
□ Diabetes
□ HIV+/AIDS
□ Kidney disease
□ Rheumatic fever
□ Hepatitis
□ Mental delays
□ Speech/hearing
□ Seizures
□ Cleft lip/palate
□ Physical delays
□ Eyesight
□ Congenital birth defects
□ Personality/social
□ Cancer/tumors
□ Recurrent headaches □ Frequent Infections
□ Adverse drug reactions
□ Cerebral palsy
□ Significant injuries
□ Endocrine/growth
□ Autism
□ Arthritis
□ ADHD
□ Spina bifida
□ Snoring
□ Abuse
Other: ____________________________________________________________________________________________
If any boxes checked, please describe further:_____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I certify that I have read and understand the above information on both sides of this form to the best of my knowledge. All questions
have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. I also
understand it is very important to report any changes in my child’s medical or dental status to the dentist at the earliest possible time,
and I agree to do so. I give permission to the dentist to obtain any additional information from my child’s physician regarding his/her
medical history needed to provide the best dental treatment possible.
I give consent for Dr. Kearney and staff to perform a dental examination, dental prophylaxis (cleaning), fluoride treatment and
take x-rays on my child.
: Signature ________________________________________________Date __________________
PERSON COMPLETING THIS FORM
Relationship to Patient: ________________________________________________________________________________________
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