Download Child Registration Form - VanderLaan Family Dentistry

Patient Name: ________________________________________ Today’s date: __________________
Patient Dental History (Child)
Is this the child’s first visit to the Dentist?..............................................................................................................
Date of last Dental visit: _______________________
□Yes □No
□Yes □No
Has the child had any serious trouble associated with previous dental treatment? .............................................. □Yes □No
Is this visit because of pain or injury?.....................................................................................................................
If “Yes”, explain: _____________________________________________________________________________________________
Please select if the following symptoms or issues apply:
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Cavities
Toothache
Broken teeth
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Extracted teeth
Orthodontic treatment
Gum infection
Frequent cold sores
Frequent canker sores
Swelling or lump in mouth
Patient Medical History (Child)
Physician: __________________________ Phone #:_________________________Date of Last Exam: _____________
Has the child been hospitalized or under the care of a physician in the last five years? □Yes
□No
If “Yes”, reason: ______________________________________________________________
Is the child allergic to any medications? □Yes
□No
(If “Yes”, please select)
□Penicillin □Codeine □Latex □Local Anesthetics □Sulfa Drugs □Aspirin □Jewelry/Metals □Other (list):
_________________________________________________________________________________________________
Is the child currently on any prescription or over the counter medications, vitamins, nutritional or herbal supplements? □Yes
□No
(If “Yes”, please list below) ________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
(Over)
Please select any that apply to the child:
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Need antibiotic pre-medication prior to dental
work?
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Undergone Radiation or Chemotherapy?
Has the child ever required a blood transfusion?
Subject to prolonged bleeding?
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Excessive thirst and/or urination?
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(Female) Currently pregnant? (______# Weeks)
Recent unusual weight loss?
(Female) Taking birth control medications?
Family history of Diabetes?
Does the child have / have had / have received treatment for any of the following diseases or
conditions? Please select all that apply:
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Heart Disease
Other Heart Issues
Mitral Valve Prolapse
High Blood Pressure
Low Blood Pressure
Artificial/ Replacement Heart
Valves
Rheumatic Heart Disease
Congenital Heart Disease
Heart Murmur
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Anemia
Hemophilia
Blood Disorder
Fainting
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Seizures
Epilepsy
Liver Disease
Kidney Disease
Asthma
Sinus Issues
Seasonal Allergies
Hives
Cancer(type_____)
Diabetes
(type____)(AIC____)
Rheumatic Fever
Neck/ Back Problems
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AIDS/HIV Infection
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Ulcers/Stomach Issues
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Eating Disorder
Sexually Transmitted
Diseases
Arthritis
Hepatitis (type____)
Tuberculosis
Scarlet Fever
Respiratory Problems
Emphysema
Psychiatric or Emotional
Disorders
Thyroid Issues
Does the child have any other medical or health condition which is not listed? □Yes □No
(If “Yes”, please list):
___________________________________________________________________
To the best of my knowledge, all of the preceding answers are true and correct. If there are
any changes in my child’s health or medications, I will inform Dr. VanderLaan at his/her next
appointment.
Signature of Parent or Guardian
Date