-
Step 4 - Medical History:
Your child's Medical History is important to our office and often contributes to your child's oral care.
Although dental personnel primarily treat the area in and around your mouth. Your child's mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationships with the dentistry you will receive. Thank you for answering the following questions.
Please mark a "YES" for any of the following items that contribute to your child's medical history. Any additional information may be entered in the text field below.
-
Allergic to Metal*
Please select Yes or No
-
Allergic to Latex*
Please select Yes or No
-
Allergic to Sulfa Drugs*
Please select Yes or No
-
Allergic to Other (Please List Below)*
Please select Yes or No
-
Currently Under Physicians Care*
Please select Yes or No
-
Previous Hospitalizations*
Please select Yes or No
-
Previous Major Operation*
Please select Yes or No
-
Previous Head Injury*
Please select Yes or No
-
Previous Neck Injury*
Please select Yes or No
-
Previous Blood Tranfusion*
Please select Yes or No
-
Current or Previous Chemotherapy*
Please select Yes or No
-
Current or Previous Cold Sores*
Please select Yes or No
-
Current or Previous Fever Blisters*
Please select Yes or No
-
Current or Previous Fainting or Diziness*
Please select Yes or No
-
Previous or Current Kidney Problems*
Please select Yes or No
-
Previous or Current Liver Disease*
Please select Yes or No
-
Currently Taking Pills or Drugs*
Please select Yes or No
-
Currently on a Special Diet*
Please select Yes or No
-
Currently Use Tobacco*
Please select Yes or No
-
Diagnosed with ADHD/ADD*
Please select Yes or No
-
Diagnosed with Autism*
Please select Yes or No
-
Diagnosed with Anemia*
Please select Yes or No
-
Diagnosed with Asthma*
Please select Yes or No
-
Diagnosed with Blood Disease*
Please select Yes or No
-
Diagnosed with Cancer*
Please select Yes or No
-
Diagnosed with Diabetes*
Please select Yes or No
-
Diagnosed with Epilipsy*
Please select Yes or No
-
Diagnosed with Heart Murmur*
Please select Yes or No
-
Diagnosed with High Blood Pressure*
Please select Yes or No
-
Diagnosed with Low Blood Pressure*
Please select Yes or No
-
Breathing Problem*
Please select Yes or No
-
Experience Convulsions*
Please select Yes or No
-
Experience Seizures*
Please select Yes or No
-
Experience Excessive Bleeding*
Please select Yes or No
-
Frequent Cough*
Please select Yes or No
-
Hay Fever*
Please select Yes or No
-
Mitral Valve Prolapse*
Please select Yes or No
-
Psychiatric Care*
Please select Yes or No
-
Rheumatic Fever*
Please select Yes or No
-
Sickle Cell Disease*
Please select Yes or No
-
Sinus Trouble*
Please select Yes or No
-
Spina Bifida*
Please select Yes or No
-
Stroke*
Please select Yes or No
-
Swelling of Limbs*
Please select Yes or No
-
Thyroid Disease*
Please select Yes or No
-
Tonsilities*
Please select Yes or No
-
Tuberculosis*
Please select Yes or No
-
Tumors or Growths*
Please select Yes or No
-
Ulcers*
Please select Yes or No
-
Yellow Jaundice*
Please select Yes or No
-
My child has medical information, a handicap, or disability not listed above.*
Please select Yes or No
-
Explanation from Medical
Please use this field to describe any illness checked above or to list additional medical history for your child.
-
Invalid Input
-
Medicines
Please provide a list of any medicines your child is currently taking. Please include both prescription and over the counter medicines.
-
Invalid Input
-
Child's Physician
Please provide us your child's physician's name and contact information.
-
Physician's Name
Please let us know your name.
-
Physicians Address
Please let us know your name.
-
Physician's Phone
Please enter a valid phone number
-
How often does your child brush?
Please specify a number.
-
How often does your child floss?
Please specify a number.
-
Is your child's water fluoridated?
Invalid Input
-
Previous Dentist
Please provide us your child's previous dentist name and contact information.
-
Dentist Name
Please let us know your name.
-
Dentist Address
Please let us know your name.
-
Dentist Phone
Please enter a valid phone number
-
Please provide your last Dental Visit
/ / Invalid Input
-
Authorization and Release
By submitting this form, I attest that I am authorized to provide the requested information for the child listed. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I also authorize the dental staff to perform necessary dental services my child may need. I acknowledge the receipt of Health Insurance Portability and Accountability (HIPPA) Information. I authorize the dentist to release any information including the diagnosis and the records of treatment of examination rendered to my child during the period of such care to third-party payers and /or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dentist’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
-