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Introductory Information
Gender
Type
By providing your cell phone number, you consent to being contacted at that number by our practice and our representatives regarding treatment and your account.
Siblings
Have they been a patient of our prctice?
Have they been a patient of our prctice?
Have they been a patient of our prctice?
Have they been a patient of our prctice?



Whom may we thank for referring your child to our practice?
Whom may we call in case of an emergency?
Pediatrician
Specialist

Health History
Although dental personnel primarily treat the area in and around the mouth, the mouth is a part of your entire body. Health problems that your child may have, or medication that your child may be taking, could have an important affect in the dental treatment your child receives. Thank you for thoroughly answering the following questions.
Medical
Is your child under medical care?
Has your child been hospitalized?
Has your child ever had any serious illness or operation?
Does your child have any seasonal allergies?
Is your child on a gluten free diet?
Was your child born premature?
Does your child bruise easily?
Does he/she have any blood disorders?
Has he/she ever required a blood transfusion?
Has your child had abnormal bleeding associated with any previous surgery, extraction or cuts?
Does your child urinate more than 6 times a day
Is your child thirsty much of the time?
Is your child wheelchair bound?
Does your child snore?
Is your child undergoing any type of therapy?
If yes, what type?
Does your child have any known allergies or has child ever reacted adversely to any of the following:
Codeine

Latex

Local Anesthetics

Penicillin or other antibiotics

Sulfa Drugs

Sedatives

Tree Nuts

Food

Is your child taking any of the following medications?
Antibiotics or Sulfa Drugs

Asthma Medications

Aspirin

Anticoagulants (blood thinners)

Blood Pressure

Tranquilizers

Cortisone or Steroids

Dilantin or other Anticonvulsant

Insulin, Tolbutamide, Orinase, or similar drug

Iron Supplements


Has your child had or does your child currently have any of the following?...
ADD/ADHD

AIDS/HIV

Anemia

Arthritis/Inflamatory Rheumatism

Asthma

ASTHMATIC PATIENTS ONLY
Has your child ever been hospitalized due to asthma?
Does your child use an inhaler?
Does he/she have a nebulizer at home?
What triggers their asthmatic episodes?
Autism

Cancer/Leukemia

If yes, please complete the following:
Does your child currently have his or her blood counts checked on a regular basis?
Has your child undergone chemotherapy?
Cerebral Palsy

Cleft

Cystic Fibrosis

Development Delayed

Diabetes

Down Syndrome

Eczema

Epilepsy

Fainting spells/Dizziness

Hearing disability
Wears a hearing aide

If they do wear a hearing aide

Hemophilia

Hepatitus
If yes, what type?

High Blood Pressure

Hives or Skin rash

Hypoglycemia

Irregular heartbeat

Jaundice
If yes, at birth only?

Kidney trouble

Liver disease

Low Blood Pressure

Persistent cough or cough up blood

Psychiatric care

Reflux

Seizures

If yes, what type of seizures

Sickle Cell Disease

Sleep Apnea

Spina Bifida

Stomach/Intestinal Disease

Tuberculosis (TB positive skin test

If yes, results of chect x-ray

Tumors or growths

Ulcers

Venereal Disease

Visually Impaired
If yes, they wear:

Dental
Is this your child's first dental visit?
Does your child have a disability that prevents treatment in a dental office setting?
Has he/she had any serious trouble associated with previous dental treatment?
Do your child's gums bleed when brushing?
Has he/she ever been treated for any type of gum disease?
Does your child grind or clench his/her teeth?
Has he/she had toothaches or sores in his/her mouth or jaws?
Has he/she had orthodontic treatment (braces)?
Have you been satisfied with your child's previous dental care?

DISCLOSURE AND CONSENT OF PARENTS
To the best of my knowledge, all of the proceeding answers are true and correct. I understand, if there is any change in my child's health history and/or the medications he/she takes, I will inform the doctor at the next appointment without fail.