Medical History:

Has your child ever had any of the following medical Problems?

Y N Allergies Y N Anemia Y N Asthma Y N Bleeding Disorder Y N Bronchitis Y N Cancer/Chemotherapy Y N Cerebral Palsy Y N Congenital Heart Defect Y N Heart Murmur Y N Downs Syndrome

Y N Convulsion/Epilepsy Y N Diabetes Y N Drug/Alcohol Abuse Y N Fainting Y N Handicap/Disabilities Y N Hearing Impairment Y N Hepatitis Y N HIV/AIDS Y N OCD Y N Autism Y N Thyroid disorder

Y N Lung Problems Y N Mental Disorder Y N Nervous System Disorder Y N Rheumatic Fever Y N Speech Disorder Y N Tuberculosis Y N Tumors/Growths Y N ADD/ADHD Y N ODD Y N Kidney Problems

Has your child experienced any other physical or mental disorder that is not listed above? Yes_____ No_______

If yes, please describe:____________________________________________________________________________________

Parents, if yes to any above please explain____________________________________________________________________

______________________________________________________________________________________________________

Is your child adopted? Yes _______ No _______

Doctor’s Comments______________________________________________________________________________________

Is your child allergic to any of the following drugs?

Y N Penicillin Y N Amoxicillin Y N Erythromycin Y N Codine Y N Dental Anesthetic

Is your child allergic to any other drugs? Yes______No_______ If yes please list ____________________________________

Is your child allergic to latex, red dye, eggs, or anything we need to be aware of? Yes __ No__ If Yes please list_____________

______________________________________________________________________________________________________.

Is your child presently under the care of a physician for any illness? Yes___ No ___ If Yes please explain__________________

______________________________________________________________________________________________________.

List any drugs or medicines presently being taken:______________________________________________________________

Has your child ever been hospitalized? Yes ___ No ___ If Yes, please give reasons and date(s)__________________________

______________________________________________________________________________________________________.

Dental History:

Do you want complete treatment for your child? Yes___ No ___

Why did you bring your child to see us today?_________________________________________________________________

Is this your child’s first visit to the dentist? Yes___ No ____

Has your child ever had a serious/difficult problem associated with previous dental work? Yes ___ No ___

If Yes, please explain________________________________________________________________________________________________

Date of last dental visit__________ Name of Dentist___________________ For what service___________________________

Were any x-rays taken? Yes ___ No ___ If Yes, have x-rays been sent to our office?______ Date requested________________

How do you expect your child to behave in our office?__________________________________________________________

Y N Does your child brush his/her teeth daily?

Y N Do you assist child with tooth brushing?

Y N Is dental floss used?

Y N Does your child take any type of fluoride supplement?

Y N Any mouth habits (thumb sucking, nail biting, mouth breather, nursing bottle habits, pacifier, etc.)

Y N Any injuries to mouth, teeth, head? Dates_____________________________________________________________

May we request the release of your child’s medical records?______________________________________________________

Thank you for your help. If there is any information that you feel might be of value to us in the treatment of your child, please

add it here: ____________________________________________________________________________________________

I give my consent to needed dental treatment and the use of proper and acceptable methods to complete said treatment for my child,

(child’s full name)______________________________. I accept responsibility for payment of services rendered.

Signed (Parent or Guardian)______________________________________________Date_____________________________