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Medical History
Date: ________________________
Patient’s Name ___________________________________________________ Age _____ Sex _____
Date of Birth _______________________ Grade ______ School ______________________________
Address ___________________________________ City _________________ State ____ Zip ______
Father’s Full Name ____________________________________________ Birthdate ______________
Father Employed By ___________________________________ Social Security No. ________________
Father’s Home Phone ______________ Work Phone_____________ Email Address ________________
Mother’s Full Name ____________________________________________ Birthdate ______________
Mother Employed By ___________________________________ Social Security No. ________________
Mother’s Home Phone _____________ Work Phone_____________ Email Address __________________
Marital Status of Parents ____ Married ____ Separated ____ Divorced
____ Other ________________
Name and number of nearest relative not living with you ________________________________________
_______________________________________________________________________________
Whom may we thank for referring you to our office? ___________________________________________
Do you currently have Dental Insurance? ___________________________________________________
Insurance Company _________________________________________________________________
Address _________________________________________________ Phone ___________________
Policy Holder ____________________________ Employer ID# ______________ Group# ___________
PAYMENT OF PROFESSIONAL FEES: Payment for dental services in this office will be cash, check, Visa,
MasterCard and Care Credit. Co-payment is DUE THE DAY that services are rendered. Portions of the bill not
covered by insurance are the responsibility of the parent or guardian. Medicaid recipients must present a current
Medicaid Card on the day of the visit. I understand and agree to these terms.
Date ___________________________ Signature _________________________________________
Has your child ever had or been treated by a physician for: (check only those that apply)
(CHECK)
______
______
______
______
______
______
______
______
______
______
(CHECK)
Hearing problems
Eye problems
Skin problems
Tonsil/adenoid problems
Sleep problems
Emotional/behavior problems
Attention deficit disorder
Hepatitis
AIDS or HIV+
Cleft lip/Palate
______
______
______
______
______
______
______
______
______
______
(CHECK)
Problems at birth
Heart murmur
Heart disease
Rheumatic fever
Anemia
Sickle Cell Anemia
Bleeding/Hemophilia
Blood transfusion
Kidney disease
Speech problems
______
______
______
______
______
______
______
______
______
Cancer
Cerebral Palsy
Seizures
Autism
Diabetes
Asthma
Arthritis
Liver disease
Tuberculosis
If your child taking any medications at this time? _____________________________________________
If so what? _______________________________________________________________________
Allergies (Please list) _________________________________________________________________
Name of patient’s physician _____________________________ Date of last physical exam ____________
Dental History
What is your main concern about your child’s dental health? ______________________________________
_______________________________________________________________________________
Has your child been to a dentist before? ____ Yes ____ No, If yes, date of last visit _____________________
Date of X-rays _____________________________________________________________________
Former dentist’s name _______________________________________________________________
Reason for leaving former dentist ________________________________________________________
(CHECK ONE)
Yes
No
_____ _____ Has your child experienced an unusual reaction to dental medication or anesthetic? If yes, explain.
_____ _____ Has your child experienced prolonged bleeding following dental treatment? If yes, explain.
_____ _____ Will your child be uncooperative? If yes, explain.
_____ _____ Has your child experienced any complications following dental treatment? If so, explain.
_____ _____ Has your child inherited any family facial or dental characteristics? If yes, explain.
_____ _____ Has your child had any injury to the teeth, jaws or face? If yes, explain.
_____ _____ Has your child had any clicking or pain in the jaw joints? If yes, explain.
_____ _____ Was your child breast fed? When stopped? _____________________________________
_____ _____ Was your child bottle fed? When stopped? ______________________________________
_____ _____ Did your child us a pacifier? When stopped? ____________________________________
_____ _____ Did your child suck a finger or thumb? When stopped? _____________________________
_____ _____ Does your child brush his/her own teeth?
_____ _____ Does your child use dental floss?
_____ _____ Do you usually help your child brush?
_____ _____ Do your child’s gums bleed when brushed?
_____ _____ Did you or your child ever get instructions in brushing?
_____ _____ Does your child use fluoride products: rinses, drops, tabs?
Cavities
Color of teeth
Teeth sensitive to hot or cold
Bleeding gums
Tooth aches
Gum infection
Teeth sensitive to sweets
Appearance of teeth
Teeth bumped
Grinds teeth
Other dental problems
Explanations and comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
To the best of my knowledge, the answers I have given are accurate. I understand it is important to report changes in my
child’s medical or dental status to the dentist, and I agree to do so. I give permission to the dentist to obtain additional
information from my child’s physician regarding medical history needed to provide dental treatment.
PERSON COMPLETING THIS FORM: Signature ________________________________ Date _________
Relationship to patient _______________________________________________________________
Medical and Dental History reviewed by ______________________________________ Date _________