Child Health History - Murray Scholls Family Dental

  • Child Health History

  • PARENT/GUARDIAN: The purpose of th following is to determine if your child has a medical condition that may require special care. All information is confidential and kept in your child’s dental record. Please complete this form and remain in the dental offic while your child is receiving treatment.

  • Date of child's last medical examination
     - -

  • Medical History

  • Is the child taking any medicines now, including birth control pills, aspirin, tylenol?*
  • Is the child being treated by a physician now?*
  • Has the child ever taken the prescription diet drug:*
  • If Yes
  • Has the child ever had any injuries to the face or jaw? *
  • Does the child bleed excessively with cuts or dental extractions?*
  • If female, is the child pregnant?*
  • Is the child allergic to any of the following? (if yes, check all that apply)
  • Is the child allergic to other medicines not listed?*
  • Is the child allergic to any foods?*
  • Rows
  • Was child born of a normal 9 month pregnancy?
  • Has child ever been hospitalized?*
  • Is child physically or mentally handicapped in any way?*
  • Does child need an update on immunizations?*
  • Has child ever received general anesthesia or sedation?*
  • Is child in the grade appropriate for his/her age?*

  • I have answered these questions for the patient (child) to the best of my knowledge and ability.

  • Clear
  • Date*
     - -
  • Why have you come to the dentist today?*
  • Did child have X-rays taken at that time?
  • What was the reason for child seeking dental treatment at that time?*
  • Has child previously complained about dental problems?
  • Is child extremely nervous or anxious while receiving dental treatment?
  • Are you (parent/guardian) nervous or anxious while you are receiving dental treatment?
  • Has child had any injuries to the mouth, teeth or head?
  • Has child ever had dental X-rays taken?
  • Does child have any mouth habits (thumbsucking, nail biting, mouth breathing, nursing bottle habits, pacifier, etc.)?
  • Does child have unusual speech habits?*
  • Has child worn orthodontic appliances now or in the past?*
  • Is child assisted with tooth brushing?*
  • Does child use toothpaste?*
  • Is child's drinking water fluoridated?*
  • Is child taking fluoride in any other form?*
  • Has any member of the family ever had an unusual dental history, such as missing or extra teeth?*
  • Does child snack or frequently consume sugar such as gum, soda pop, Life Savers or fruit juices?*
  • Should be Empty: