Toothbud Medical/Dental History

Thank you for choosing Toothbud for your child's / children's dental home. This form needs to be completed for each child being seen as a patient at Toothbud. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party.

Tell Us About Your Child

Child's Name

Today's Date

Child's Birthdate

Child's (Children) Physician

Physician Phone

How did you find Toothbud Pediatric Dentistry?

If other, Please indicate

List all ALLERGIES to any Drugs, Foods, Materials, Environment (or write "none"):

Please discuss any medical conditions your child has (if none, write "none")

List all drugs your child is currently taking (and dosage if known), or write "none"

Are there any other details of your child's health that we should be aware of?

Dental History

Is this your child's first visit to the dentist?

Yes No

If no, how long since the last visit to the dentist?

Previous Dentist's Name

What concerns or questions would you like to discuss with Dr. Dimick when you come?

Check any of the habits your child may have.

Thumb/ Finger habit

Pacifier habit after 3yrs old

Nail Biting

Does your child have any Current Dental Issues?

Cavities

Bleeding Gums

Bad Breath

Mouth Trauma/Broken Tooth

Toothaches

Discolored Teeth

Teeth Grinding

Sensitivity to Hot/Cold

Social History: Child's First Language

Child's Second Language

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.

Name / Signature

Date

Your information will be encrypted.