Child Medical History Form

    We are pleased to welcome you to our practice. Please complete this form. The following information is necessary to enable us to provide your child with the best dental care possible. All information disclosed is confidential and shall only be used for dental and medical purposes.








    Mother's Information




    Date of Birth




    Father's Information




    Date of Birth





    Parent's Marital Status:



    Who has legal custody of the child (if applicable):



    Is patient a foster child?


    If yes, please provide court documents.


    Contact Person in case of Emergency:





    Medical History




    Date of last physical exam:


    Is patient in good health?



    Has patient ever had health problems/been hospitalized?




    Is patient currently taking any medication?



    Have you ever been told that patient needs antibiotics before dental treatment?



    Does patient have any food allergies?



    Does patient have any allergies to meditation?



    Is patient allergic to latex?



    Does patient have any other allergies?




    Does patient have or has patient ever had the following conditions?

    ArthritisAsthma DiabetesGI Disorder Heart Disease Kidney Disease Rheumatic FeverADHD Anxiety/Nervousness AutismEmotional Disability Learning Disability Behavior Issues Psychiatric DisorderHepatitis HIV Infection TuberculosisAnemiaBleeding (Prolonged) HemophiliaBrain InjuryCerebral PalsyCleft Lip/Palate Developmental Delay Eating Problems Growth Problems SeizuresSpeech Problems Hearing Loss Neuromuscular Defect Orthopedic ProblemsCancerLeukemiaFainting/HeadachesGag ReflexSleep ApneaSleep ProblemsSnoring



    Dental History

    Is this the patient's first visit to the dentist?



    If no, when was the last visit?





    Please check any of the following that may describe the patient's attitude towards dentistry:




    Does patient have any of the following habits?


    Nursing bottleNail bitingPacifier suckingThumb/Finger suckingTeeth grindingCheek/Lip bitingJaw ClenchingMouth breathing



    Has the patient had any unhappy dental experience?



    Has the patient had local anesthesia (Novocain)?



    Does the patient brush his/her teeth?



    Do you assist in brushing the patient’s teeth?



    Does the patient use dental floss?



    Does the patient use fluoride in any form?



    Does the patient have sugar snacks? (e.g. raisins, fruit rollups, candy, etc.)



    Does the patient drink soda and/or juice?