Child Medical And Dental History Form - Williamson!pediatric!dentistry
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2Williamson P ediatric D entistry
2055 W all S treet
Spring H ill, T N 3 7174
( 615) 6 14-‐2424
(615) 6 14-‐2426 f ax
MEDICAL AND DENTAL HISTORY FORM
I)
General Information
Patient:
Address (City, State, ZIP):
Age:
Date of Birth:
Gender: M/F
Siblings (Name & Age):
Responsible Party:
School Attended:
Referred By:
Physician/Pediatrician:
Physician Address & Phone #:
Date of Last Medical Examination:
Hobbies / Interests:
II)
Medical History
Has your child ever had any of the following medical diagnoses?
1)
A. Learning, behavioral, or communication problems?
Yes/No
B. Cerebral palsy, seizures, convulsions, loss of consciousness,
recurrent headaches, traumatic head/brain injury?
Yes/No
C. Sensory Disorders – seeing / hearing?
Yes/No
D. Congenital heart disease, murmurs, rheumatic fever, heart surgery?
Yes/No
E. History of high blood pressure or chest pains?
Yes/No
F. Bleeding disorders, dyscrasias, anemia, sickle cell disease?
Yes/No
G. Lymphatic problems (swollen lymph nodes / glands)?
Yes/No
H. Asthma, cystic fibrosis, pneumonia, difficulty breathing?
Yes/No
I. Stomach, liver, intestinal problems, hepatitis, jaundice?
Yes/No
J. Kidney or bladder disease, history of urinary tract infections?
Yes/No
K. Women only: Pregnancy or possible pregnancy?
Yes/No
L. Diabetes, thyroid, or other endocrine disorders?
Yes/No
M. Limitation of arms or legs, joint replacement, muscular dystrophy?
Yes/No
N. Other:
Yes/No
2) Has your child ever experienced the following:
A. Allergic reaction to any medication?
Yes/No
If so, what medication and what kind of reaction?
B. Other allergies (e.g. LATEX, NUTS, DYES, etc.)?
Yes/No
3) Is your child currently taking any medications?
Yes/No
If yes, please list:
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