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Download HEALTH HISTORY Please check yes or no if your child has been
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HEALTH HISTORY Patient Name: ________________________________________________ Child’s Physician (Office and Doctor’s Name) ______________________________________________________________________________________________ Phone Number of Physician’s Office _________________________________________________ Date of Last Physical _________________________________ Are Immunizations Up to Date? Yes No Is Your Child in General Good Health? Yes Has Your Child Ever Been Hospitalized or Had Any Kind of Surgery? No Yes No If so, Please explain and give date _________________ ___________________________________________________________________________________________________________________________________________ Yes Is Your Child Allergic to any Antibiotics/Drugs? No If Yes, Please Explain What and What Type of Reaction _______________ __________________________________________________________________________________________________________________________________________ Yes Is Your Child Allergic to Anything Else (i.e: latex, dyes, etc)? No If Yes, Please Explain What and What Type of Reaction ________________________________________________________________________________________________________________________________________ Please check yes or no if your child has been diagnosed or treated for any of the following: YES ASTHMA ENIRONMENTAL /SEASONAL ALLERGIES ADHD/ADD AUTISM SPECTRUM DISORDER DOWN’S SYNDROME CEREBRAL PALSY CLEFT LIP/PALATE MENTAL DELAYS PHYSICAL DELAYS NEUROLOGICAL PROBLEMS NO YES NO YES HEART DISEASE TYPE ______________ LIVER DISEASE TYPE ______________ KIDNEY DISEASE TYPE ______________ CANCERS/TUMORS TYPE ______________ PERSONALITY/SOCIAL DISORDERs VISION PROBLEMS ACID REFLUX/GERD NO BLEEDING DISORDERS ANEMIA TYPE _____________ SEIZURES/EPILEPSY DIABETES TYPE _____________ HEPATITIS TYPE _____________ AIDS/HIV SPEECH/HEARING DIFFICULTIES EATING DISORDERS OTHER (NOT LISTED) _____________________________________________________________________________________________________________________ PLEASE ELABORATE ON ANY MEDICAL INFORMATION MARKED _____________________________________________________________________________ Is There Any Significant Family History Of Diseases /Oral Cancers? Is Your Child Currently Taking Any Medications? Yes Yes No No Explain:_________________________________________________ If Yes, Please Explain Below Drug Name _______________________________________ Dosage/Frequency ___________________________________ Reason _______________________ Drug Name _______________________________________ Dosage/Frequency ___________________________________ Reason _______________________ DENTAL HISTORY Are There Any Specific Concerns/Questions Regarding Your Child’s Mouth/ Teeth?__________________________________________________________ Yes Has Your Child Ever Suffered Any Injuries to The Mouth or Teeth? No If Yes, Please Explain _____________________________________ _________________________________________________________________________________________________________________________________________ Has Your Child Ever Seen a Dentist? Yes No If So, Name of Dentist and Date of Last Exam _________________________________________ Has your child previously had a negative experience at the dentist? Yes No If So, Please Explain_______________________________ __________________________________________________________________________________________________________________________________________ Is There Anything You Can Tell Us To Help “Connect” With Your Child? (i.e: Princesses, Trains, Spiderman, Family dog, etc.)_________________________________________________________________________________________ Does your child currently do any of the following? (please check all that apply): Breast Feed Bottle Feed Grind Thumb/Finger Suck Use a Pacifier NONE What Type of Water Is Present In Your Home? Filtered Water (from the tap or fridge) Does Your Child Use Fluoride Toothpaste? Reverse Osmosis Yes No Well Water Bottled Water Any Other Forms Of Fluoride? (Rinse,Vitamins, etc.)____________________________
