MEDICAL & DENTAL HISTORY
Child’s Name_________________________________________
Home Address________________________________________
Phone: Home ___________________ Cell __________________ e-mail__________________________
Age _______ Birth date __________________ Birthplace ___________________
School _____________________________________________
Grade __________
Father’s Name _______________________________________ Occupation ___________________________
Employed by ________________________________________
Work Phone __________________________
Mother’s Name ______________________________________ Occupation ___________________________
Employed by ________________________________________
Work Phone __________________________
Child’s Physician_____________________ Phone___________ Date of last check-up ___________________
In Case of Emergency Notify________________ Phone _________ Relationship __________________________
Who may we thank for referring you? __________________________________
Medical History:
1. Has your child ever had any serious illness or treatment in a hospital? _____________________________
2. Is your child currently taking any medication? If yes, please list. __________________________________
3. Is your child allergic to any medication or food? _______________________________________________
4. Has your child ever had any unfavourable reaction to any previous medical or dental care? ____________
5. Do you have or have you ever had any of the following?
Measles
Mumps
Chicken Pox
Scarlet Fever
Strep Throat
Pains in chest
Bruise easily/Prolonged bleeding
Jaundice/ Liver disease
Please underline all that apply
Asthma
Tonsillitis
Hay Fever
Diabetes I or II
Fainting spells
Heart trouble
Blood Disease
Kidney disease
Shortness of Breath
Lung disease
Muscular Dystrophy
Ear Aches
Cancer
Rheumatic fever
Epilepsy/Nervous disorder
Psychiatric care
Dental History:
1. Has your child had previous dental care? If so how long ago? ____________________________
2. Has your child ever had an accident, injury or surgery to the mouth? ______________________
3. Has your child had an unpleasant experience associated with a dental visit? ________________
4. How often does your child brush his/her teeth? ______times/day
5. Does your child have any of the following oral habits:
Thumb sucking
Finger sucking
Lip biting
Nail biting
Mouth breathing
Teeth grinding
6. Is there a family history of:
High cavity rate
Extra teeth
Gum disease
Missing teeth
Tongue thrusting
Other ________
Malformed teeth
Crooked teeth
Parent’s Consent for Children Under 18
I hereby consent to the performing of the Dental procedures necessary and recommended for my children, including the
use of Local Anesthetic as indicated. I accept responsibility for the fees.
Patient’s (Parent’s) Signature_______________________________ Date____________