New Pt Medical History Form

Patient Medical History Form
PATIENT'S FULL NAME

First NameLast Name
MIDDLE INITIAL
NICKNAME
SEX
AGE
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SCHOOL
GRADE
REASON FOR VISIT
REFERRED TO THIS OFFICE BY (We wish to thank them)
MEDICAL HISTORY
CHILD'S PHYSICIAN
DATE LAST SAW PHYSICIAN
MONTH/YEAR
CITY
PHONE NUMBER

Area CodePhone Number
IS YOUR CHILD PRESENTLY UNDER THE CARE OF A PHYSICIAN FOR ANY MEDICAL REASON?
WHAT?
PHYSICIAN NAME & PHONE #
IS YOUR CHILD CURRENTLY TAKING ANY MEDICATION?
WHAT?
HAS YOUR CHILD EVER BEEN HOSPITALIZED OR HAD SURGERY?
FOR WHAT?
IS YOUR CHILD ALLERGIC TO ANY FOOD OR MEDICINE?
WHAT?
HAS YOUR CHILD HAD A HISTORY OF:
ADHD / ADD
ANEMIA
ALLERGIES
ASTHMA / BREATHING ISSUES
AUTISM SPECTRUM
BLEEDING DISORDER
BRAIN INJURY
CANCER / MALIGNANCY
CARDIAC DISEASE / MURMUR
CEREBRAL PALSY
CHEMO / RADIATION
CYSTIC FIBROSIS
DELAYED DEVELOPMENT
DEPRESSION / ANXIETY
DIABETES
DOWN'S SYNDROME
EARACHES / INFECTIONS
EMOTIONAL / SCHOOL ISSUES
EPILEPSY / SEIZURE
HEARING IMPAIRMENT
HEPATITIS
IMMUNE DISORDER
KIDNEY / LIVER ISSUES
MUSCULAR DISORDER
PREMATURE BIRTH
RHEUMATIC FEVER
SPEECH DISORDER
TUBERCULOSIS
VISUAL IMPAIRMENT
DOES YOUR CHILD HAVE ANY DISEASE, CONDITION, OR PROBLEM NOT LISTED?
IF SO, WHAT?
DENTAL HISTORY
CHILD'S FIRST DENTAL VISIT?
PREVIOUS DENTIST
CITY
PHONE #
DATE OF LAST VISIT

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE OF LAST X RAY

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ANY INJURIES TO YOUR CHILD'S TEETH OR JAWS?
WHAT?
ANY HISTORY OF (SELECT ALL THAT APPLY):
HAS YOUR CHILD EXPERIENCED ANY UNFAVORABLE REACTION FORM PREVIOUS MEDICAL OR DENTAL CARE?
EXPLAIN:
NAME OF FAMILY DENTIST
CITY
PHONE #
HOW OFTEN DOES YOUR CHILD BRUSH?
IS TOOTHBRUSHING SUPERVISED?
BY WHOM?
IS DENTAL FLOSS USED?
Type a question
To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.
SIGNATURE
PRINTED NAME
RELATIONSHIP TO PATIENT
Should be Empty:

Patient Medical History Form

MEDICAL HISTORY

HAS YOUR CHILD HAD A HISTORY OF:

DENTAL HISTORY