Additional Child Medical History Form

Child’s Name:

Birthdate:

Child's Age:

Nickname:

Gender

Male Female

Medical History:

If Other selected, Please specify

Please explain any of the above indicated, or any other serious conditions not listed:

Is there anything you would like to discuss with the doctor in private?

Please list all medications your child is taking:

Please list any allergies:

Child’s Physician:

Phone#:

Is your child up to date with immunizations?

Yes No

Dental History

Is this your child’s first dental visit?

Yes No

If no, who was the previous dentist?

Date of last visit?

Does your child have a toothache or any other immediate concern?

Yes No

Is there a history of trauma to the mouth, teeth, or jaw?

Yes No

Do you anticipate your child having difficulty with dental treatment?

Yes No

If yes, why?

Does your child have any oral habits?

Pacifier

Grinding

Nail biting

Finger/Thumb Sucking

Mouth breathing

Other

If Other selected, please specify

Does your child brush their teeth daily?

Yes No

Floss?

Yes No

Does anyone assist with brushing?

Yes No

Does your child use a fluoridated toothpaste?

Yes No

Any history or current use of fluoride supplements?

Yes No

Does your child drink:

City Water

Well water

Bottled Water

Did/Does your child: Breast feed?

Yes No

Until what age?

Bottle feed?

Yes No

Until what age?

Does your child have any dietary restrictions?

Yes No

Is this your child’s first dental visit?

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/Guardian Name:

Parent /Guardian Signature:

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