Newberg Kids' Dentist Introduction Page 2

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HEALTH   H ISTORY  
Patient   N ame:  
Date   o f   B irth:    
Primary   C are   P hysician   ( name   a nd   n umber):    
Heart  
Heart   M urmur   □         M itral   V alve   P rolapse   □           R heumatic   F ever   □           C ongenital   □             H eart   D efect   □          
 
Low/High   B lood   P ressure   □             H eart   S urgery   □           O ther   □            
Please   E xplain:   _ _______________________________  
Kidney  
Bladder   □           U rinary   P roblems   □           O ther   □           P lease   E xplain:   _ _______________________________  
Liver/GI  
Stomach/Intestine   U lcers   □           G astritis   □           C olitis   □           D iarrhea   □           J aundice   □           H epatitis   □                
 
Liver   D isease   □           R eflux   ( GERD)     □           O ther   □  
Please   E xplain:   _ _______________________________  
Endocrine  
Diabetes   □   T ype:   _ ____           T hyroid   D isease   □           O ther   □            
 
Please   E xplain:   _ _______________________________  
Hematologic  
Blood   T ransfusion   □   D ate(s)   _ _________           A nemia   □           H emophilia   □           L eukemia   □                                          
 
Sickle   C ell   D isease   □           P rolonged   B leeding   □           O ther   □            
Please   E xplain:   _ _______________________________  
Lung/Breathing  
Hay   F ever   □           S inus   T rouble   □           A llergies/Hives   □           A sthma   □           C hronic   C ough   □           E mphysema   □          
 
Tuberculosis   □           O ther   □            
Please   E xplain:   _ _______________________________  
Neurological  
Nervous   D isorder   □           M ental   D isorder   □           C erebral   P alsy   □           S eizures/Epilepsy   □           F ainting   □          
 
Autism   □         A DHD   □             D evelopmental   D elay   □           B rain   I njury   □           H eadaches   □           S peech   D isorder   □            
Please   E xplain:   _ _______________________________  
Hearing/Eye  
Vision   P roblems   □           G laucoma   □           E ye   P ain   □           E araches   □           H earing   L oss   □            
 
Please   E xplain:   _ _______________________________  
Dermal/  
Rashes   □           L atex   A llergy   □           A rthritis   □           F ever   B listers/Cold   S ores   □           U lcers   □           O ther   □            
Musculoskeletal  
Please   E xplain:   _ _______________________________  
Does   y our   c hild   h ave   a ny   d isease,   c ondition   o r   o ther   h ealth   p roblems   n ot   l isted   a bove?  
□       Y es                     □ No            
Medications   ( names   a nd   d osages)  
□       Y es                     □ No            
Has   y our   c hild   b een   h ospitalized   s ince   b irth?  
□       Y es                     □ No            
If   y es,   W hen?                                                                                       W hy?  
Has   y our   c hild   e ver   h ad   s urgery?  
□       Y es                     □ No            
If   y es,   W hen?                                                                                       W hy?  
Has   y our   c hild   h ad   r adiation   o r   c hemotherapy?  
□       Y es                     □ No            
If   y es,   W hen?                                                                                       W hy?  
Does   y our   c hild   u se   t obacco?  
□       Y es                     □ No            
Does   y our   c hild   h ave   A IDS   o r   h as   h e/she   b een   t ested   H IV   p ositive?  
□       Y es                     □ No            
Does   y our   c hild   h ave   a ny   a llergies   t o   f ood   o r   m edications?  
□       Y es                     □ No            
If   y es,   p lease   l ist:  
Is   y our   c hild   a dopted?  
□       Y es                     □ No            
If   y es,   d oes   h e/she   k now?  
Females:   a ny   p ossibility   o f   p regnancy?  
□       Y es                     □ No            
DENTAL   H ISTORY  
Does   y our   c hild   c urrently   h ave   a ny   c avities?  
□       Y es                     □ No            
Has   y our   c hild   h ad   d ental   w ork   d one   i n   t he   p ast?  
□       Y es                     □ No            
Have   t here   b een   a ny   i njuries   t o   t eeth,   s uch   a s   f alls,   b lows,   o r   c hips?   W hen?   _ _______________   □       Y es                     □ No            
Has   y our   c hild   h ad   a ny   d ifficult   d ental   e xperiences   i n   t he   p ast?  
□       Y es                     □ No            
If   y es,   p lease   e xplain:   _ _____________________________________________________  
Does   y our   c hild   t hink   t here   i s   a nything   w rong   w ith   t heir   t eeth?  
□       Y es                     □ No            
If   y es,   p lease   e xplain:   _ _____________________________________________________  
Is   t here   a ny   a dditional   i nformation   t hat   w e   s hould   k now?  
 
            P ARENT/GUARDIAN   S IGNATURE:                                                                                                                                                                                           D ATE:    
 
 

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