Download child health history - Buehler Dental Clinic

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)