Dental History Page 2
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4Medical & History
Have you ever had any of the following? Please check those that apply:
HIV or AIDS
Latex Allergy
Heart Disease
ADD / ADHD
Tumors or Growths
Hepatitis A, B, C
Pacemaker
High Blood Pressure
Mental or Nervous Disorders
Anorexia or Bulimia
Asthma w/ Inhaler use
Stroke
Anemia
Head Injuries
Arthritis / Gout
Bleeding Problems
Epilepsy or Seizures
Blood Disease
Glaucoma
Excessive Thirst
Dizziness / Fainting
Hypoglycemia
Untreated Chest pain
Thyroid Problem
Antibiotic Pre-med : Amoxicillin / Clindamycin / Other
Heart Murmur
Lung Disease or Problems
Long-term steroid medicine
Blood Thinner – Aspirin / Coumadin / Other
Mitral Valve Prolapse
Tuberculosis
Venereal Disease
Diabetes: Type ___ Last BSL? ______ Last A1C? _____
Congenital Heart Lesion
Stomach Ulcers / GERD
Cold Sores / Fever Blisters
Artificial Joints or Valves
Kidney or Liver Disease
Frequent Headaches
Cancer : Location? ______________________________
Rheumatic or Scarlet Fever
Jaundice
Pain in Jaw Joint
When Diagnosed? _________ Chemo / Radiation? (circle)
Free & Clear?
Yes
No
Other : _____________________________________________
Name of Pediatrician / Clinic: ___________________________________________
Phone:_________________
Yes
No
Is your child taking any medications? If yes, please list name and for what reason on reverse side
Yes
No
Has your child been told they needed to take antibiotic premedication prior to a dental appointment?
Yes
No
Does your child have any allergies to any medications? If yes, please list ________________________
Yes
No
Has your child been treated by a physician or hospitalized in the past year?
If yes, please explain _________________________________________________________________
Birth Weight: _________________
Current Weight: _______________
When Last Weighed: _______________
Dental History
Why did you bring your child to see us today? _________________________________________________________
Date of last dental visit: _______________ Reason for that visit: ___________________________________________
Who was your former dentist?____________________ _______ City/State: _________________________________
Yes
No
Did your child see this dentist regularly? (every 6 months for cleanings and checkup exams)
Yes
No
Is your child having any pain or discomfort at this time? If yes, where: _________________________
Yes
No
Has your child ever had a serious or difficult problem associated with previous dental work
If yes, please explain:________________________________________________________________
Yes
No
Do you or your child brush their teeth at least 2 times per day with a soft bristled or electric toothbrush?
Yes
No
Do you assist your child with tooth brushing?
Yes
No
Do you use a toothpaste with fluoride or xylitol?
Yes
No
Does your child floss at least 5 times per week? If no, how many times per week? ___ or per month?___
Yes
No
Has your child ever been told they have "gum disease" or "gingivitis" or had "gum surgery"?
Yes
No
Are you happy with the appearance of your child's teeth/gums/smile?
If not, please explain what you don't like__________________________________________________
Yes
No
Does your child have issues with L, T, D, N, SH, TH, or S sounds?
Yes
No
I don't know Is your child tongue-tied or lip-tied ?
Yes
No
Is/ was your child breast-fed? If yes, for how long? ________________________________________
Why did you stop nursing? ___________________________________________________________
Does/did your child have any of the following problems? (check all that apply)
No effective latch-on
Un-sustained latch-on
Unable to hold pacifier
Slides off nipple
Prolonged feeding times
Poor weight gain or failure to thrive
Unsatisfied hunger after feeding
Gumming or chewing on nipple
Falling asleep on the breast
Gas, Colic and /or reflux, including vomiting (circle)
Upper Lip Blisters
Others: _____________________________________________________________________________________
Have you, the mother, experienced any of the following when breastfeeding? (check all that apply)
Severe pain with latch-on
Incomplete breast drainage
Mastitis or nipple thrush
Continued pain during nursing
Infected nipples
Reoccurring Plugged ducts
Nipple trauma : Cracked , Bruised , Bleeding , Blistered, Creased , Blanched or Flattened nipples (circle)
Others: _____________________________________________________________________________________
Doctor notes:__________________________________________________________________________
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