School Dental Health Program Page 2
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2School Dental Health Program
Medical History
Student Name:
___________________________________________________
Date of Birth: ____/____/____
School_________________________________
Teacher_________________________________
Grade___________
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When did your child last visit a dentist?
In the past year
More than a year
Never
Why did your child visit the dentist?
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Cleaning/checkup
Toothache
Filling
Tooth pulled
Other
Medical History: Check all that apply
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Artificial Heart Valve
Artificial Joints Pins/Screws
Asthma
Congenital Heart Disorder
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Diabetes
Heart Disease
Hepatitis
Seizure disorder
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Heart murmur
Autism
Other_______________________________
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:
Latex
Amoxicillin/Penicillin
Other___________________
Any Known Allergies
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Is your child required by physician to take pre-medication (antibiotics) prior to dental treatment?
No
Yes
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If yes, for what condition______________________________________________________________________________
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Does your child have Special Health Care Needs ?
No
Yes
Surgeries/Hospitalizations/Other Medical Conditions: ______________________________________________________________
_________________________________________________________________________________________________________
Medications your child is currently taking? ________________________________________________________________________
_________________________________________________________________________________________________________
Other information- Please tell us anything you think we should know about your child’s health or previous dental experiences that would
help us treat your child or meet their needs._____________________________________________________________________
________________________________________________________________________________________________________
I confirm that the above health information is accurate to the best of my knowledge and I will contact the school as soon as possible if
any changes occur.
CHC/SEK will treat all patient information as protected health information (PHI) under HIPPA regulations, exchanging the PHI only with
personnel employed by CHC/SEK and the facility/school who are responsible for medical treatment and/or record review.
Parent/Guardian Signature_______________________________________________
Date_______________________
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