• Hillsboro: (503) 642-1535 • Portland (Cedar Hills): (503) 644-4749

 

Medical History Form

 

Although dentistry deals with primarily teeth and its surrounding structures, oral cavity is a part of the entire body. Health problems that your child may have, or medications that your child may be taking could have an important interation with dentistry your child may receive. Thank you for answering the following questions thoroughly.

 

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Contact Information

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

 

Date of birth: *

  

Age

Patient Gender: *

  Male   Female  

 
 

Medical History

Name of Child's Physician?:

Child Physician's Phone Number:

 

Any problems/complications durning pregnancy/delivery? If yes, please explain: *

Does your child have any health problems? If yes, please explain: *

Has your child been diagnosed with any medical conditions? If yes, please explain: *

Has your child ever been hospitalized? If yes, please explain (For & When): *

Has you child ever had surgery? If yes, please explain (For & When): *

Is your child taking any medication? If yes, please list: *

Is your child allergic to any medications/food/latex? If yes, please list: *

Are your child's immunizations up to date?: *

 

Check any of the following for which the patient has been treated:

AIDS/HIV Positive

ADHD/ADD

Arthritis

Asthma

Autism

Blood Problems

Bronchitis

Cancer

Cerebral Palsy

Diabetes

Down Syndrome

Ear Infection

Emotional Problems

Endocrine Problems

Epilepsy Seizures

Eye Problems

Hearing Problems

Heart Problems

Hepatitis A/B/C

Liver/Kidney Disease

Leukemia

Prolonged Bleeding

Rheumatic Fever

Speech Problems

Tonsillitis

Tuberculosis

Thyroid Disease

 

Dental History

Main reason for today's visit?:

How often are the child's teeth brushed?

1x/day 2x/day every other day not regularly  

How often are the child's teeth being flossed?

1x/day every other day 1x/week not regularly  

Who does the brushing and flossing?

parent child half/half none  

 

Fluoride Use?:

Rx by MD/DMD in H2O toothpaste rinse none  

When was your child weaned off nursing/bottle?

6 mos 12 mos 24 mos still use  

Does your child have any oral habits?

thumb/finger binky mouth breather grinding  

 

History of Dental Trauma? If yes, please explain:

How would you rate mother's oral health?

Excellent Good Fair Poor I don't know  

How would you rate father's oral health?

Excellent Good Fair Poor I don't know  

How would you rate your child's candy consumption? (candy, juice, etc)

low average high  

 

Is there any additional medical/dental information you may want the dentists at Hi5 Dental to know?

 
 

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Our Doctors:
Hai Pham, DMD
Jenette Intrachat, DDS
Frank Hsieh, DDS, MSD

TOP DENTIST, Portland Monthly

Dr. Pham was featured in Portland Monthly, chosen
as one of the Top Dentists, Pediatric Dentistry, 2011, 2012, 2013, 2014, 2015.

Proud Member

Hospital Privileges
Dr. Pham has hospital privileges at:


Hillsboro

Hi5 Dentistry for Kids
- New Address!

3075 SE Century Blvd Ste 109
Hillsboro, OR 97123
Phone: (503) 642-1535
map
Portland

Hi5 Dental - Pediatric Dentistry
2375 SW Cedar Hills Blvd,
Portland
, OR 97225
Phone: (503) 644-4749
map
Office Hours

Monday - Thursday: 8am to 5pm
Friday: 8am to 12pm


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Hai Pham DMD - Hi5 Dentistry for Kids | www.hi5dental.com | (503) 642-1535
2375 SW Century Blvd, Hillsboro, Or 97225



 

 

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