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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: □ □ □ □ □ □ Cavities Toothache Broken teeth □ □ □ 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: □ Need antibiotic pre-medication prior to dental work? □ □ □ □ Undergone Radiation or Chemotherapy? Has the child ever required a blood transfusion? Subject to prolonged bleeding? □ □ Excessive thirst and/or urination? □ □ (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: □ □ □ □ □ □ □ □ □ □ □ □ □ 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 □ □ □ □ □ □ □ □ □ □ Anemia Hemophilia Blood Disorder Fainting □ □ Seizures Epilepsy Liver Disease Kidney Disease Asthma Sinus Issues Seasonal Allergies Hives Cancer(type_____) Diabetes (type____)(AIC____) Rheumatic Fever Neck/ Back Problems □ □ AIDS/HIV Infection □ □ □ □ □ □ □ □ Ulcers/Stomach Issues □ □ 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