Pediatric First Visit Medical/dental History Form

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Whitney M. Frank, DDS
Pediatric First Visit Medical/Dental History Form
Patient Name___________________________
Name & Relationship of person filling out this
form___________________________
Date of Birth ____________________
Today’s Date ____________________
Although dental personnel primarily treat your child’s mouth, the mouth is a part of the entire body. Health problems or medications could
have an important relationship with the dental care your child will receive. Thank you in advance for answering the following questions.
Please list your child’s family physician and any medical specialists they see at least once a year:
NAME
SPECIALTY
PHONE NUMBER
_________________________________________________________________________________________________________
______________
_________________________________________________________________________________________________________
______________
_________________________________________________________________________________________________________
______________
YES NO Do you consider your child to be in good health?
YES NO Is your child up to date on immunizations?
Please list any history of hospitalization or surgery and the date: ________________________________________________________________
_______________________________________________________________________________________________________________________
Do your child currently have or ever had:
YES NO Allergic reactions to:
Latex
Penicillin
Codeine
Local Anesthetics
Metals
Other: _______________
Reaction: ________________________________________________________
YES NO Lactose Intolerance or Food allergy
YES NO Dietary Restrictions
YES NO Heart Bypass, Stent or Artificial Heart Valve
YES NO Congenital heart defect, rheumatic fever or rheumatic heart disease
YES NO Irregular Heartbeat
YES NO High Blood Pressure
YES NO Cystic Fibrosis
YES NO Complications before or during birth
YES NO Pre-mature birth
YES NO Problems with growth or development
YES NO Any inherited condition
YES NO GERD or acid reflux
YES NO Bladder or Kidney Problems
YES NO Jaundice, Hepatitis or liver problems
YES NO Artificial implants or devices
YES NO Bleeding problem, clotting disorder, anemia or other blood disease
YES NO Diabetes
Type I or Type II
YES NO Seizures or any other nervous system disease
YES NO Sinusitis, chronic adenoid/tonsil infections
YES NO Asthma
YES NO Sleep Apnea, snoring, mouth breathing
YES NO Cancer
Type_____________________________________________________________________
Chemotherapy (dates) __________________ Radiation (dates) ____________________
YES NO Immunosuppressive condition (circle those that apply)
Prednisone therapy
Cancer therapy
Spleen removed
Rheumatoid Arthritis
HIV/AIDS
Organ Transplant
SLE (Lupus)
Other: ____________________
YES NO Developmental or intellectual disorders
YES NO Impairment of hearing or sight or speech
YES NO Physical or mental condition that may require special care
YES NO Behavioral, emotional, communication or psychiatric problems/treatment
YES NO Abuse (physical, psychological, emotional or sexual) or neglect
YES NO Does your child have any disease, condition, or problem not listed here?
Please describe: ________________________________________________________________________________________
For any positive answer above that needs more description, use the space below:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

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