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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.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

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 pregancy/delivery?

Does your child have any health problems?

Has your child been diagnosed with any medical conditions?

Has your child ever been hospitalized? (For & When)

Has you child ever had surgery? (For & When)

Is your child taking any medication? (List)

Is your child allergic to any medicatons/food/latex?

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 Dr. Pham/Ruby to know?

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 
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