Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CHILD HEALTH HISTORY DENTAL HISTORY Childs Name: (last) ____________________ (first) ______________ (middle) ________ Date of Birth: _________ Former Dentists Name: ______________________ City: ______________ Last Date of Service: ___________ CIRCLE A DEFINITE ANSWER TO EACH QUESTION: YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO Has child complained of dental problems? (explain) _____________________________________________ Any unhappy dental experiences? (explain) ____________________________________________________ Any injuries to mouth / teeth / head? (explain) __________________________________________________ Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing bottle habit, pacifier, other) ______ Any unusual speech habits? (explain) _________________________________________________________ Any lost teeth? (explain) ___________________________________________________________________ Have missing teeth been replaced? ___________________________________________________________ Orthodontic appliances worn now or ever been? ________________________________________________ Does your child brush teeth daily? ___________________________________________________________ Do you assist your child with tooth brushing? (how often) ________________________________________ Is dental floss used? (how often) ____________________________________________________________ Are disclosing tablets used? ________________________________________________________________ Is fluoride taken in any form? _______________________________________________________________ Do you desire complete dental service for your child? ____________________________________________ Describe your child’s attitude to dentistry: _______________________________________________________ __________________________________________________________________________________________ MEDICAL HISTORY Child’s Physician: _________________________ City: ____________ Date of last physical examination: ___________ YES YES YES YES YES NO NO NO NO NO Is child under care of physician now? Is child receiving any medication or drugs? Is there any excessive bleeding when cut? Other allergies: food, pollen, animals, dust, etc. Has child ever had surgery? _____________ YES NO Does child have good physical coordination? YES NO Are there any emotional problems? YES NO Any allergy to penicillin or other drugs? YES NO Has Child ever been hospitalized? ________ HAS CHILD ANY HISTORY OF OR DIFFICULTY WITH ANY OF THE FOLLOWING? YES YES YES YES YES YES NO NO NO NO NO NO Anemia Aids Thyroid Liver Heart Kidney YES YES YES YES YES YES NO NO NO NO NO NO Bladder Epilepsy Mastoid Measles Diabetes Hearing YES YES YES YES YES YES NO NO NO NO NO NO Cerebral Palsy Chicken Pox Convulsions Mononucleosis Fainting Asthma YES YES YES YES YES YES NO NO NO NO NO NO Rheumatic Fever Malignancies Tuberculosis Chronic Sinus Venereal Disease Mumps Please describe any current medical treatment including drugs, pending surgery, recent injuries, or any other information we should be aware of that has not been disclosed or discussed._______________________________________________ __________________________________________________________________________________________________ May we request release of your child’s medical records for our reference? YES NO This information was discussed with and given by (Responsible Party Name) ___________________________________ I certify the above to be true and correct to the best of my knowledge. SIGNITURE: __________________________________________________ DATE: ____________________________ (Parent or Guardian)