Past Medical and Dental History

Child's Name:

Date of Birth:

Age:

Medical History

1. Please list your child's pediatrician or primary medical doctor. If your child is under the care of any other physician, please list.

2. Is your child taking medications? Yes No

If yes, please list:

3. Does your child have any allergies? Yes No

If so, what type:

Drug:

Food:

Seasonal:

Latex:

Other:

4. Are immunizations current? Yes No

5. Please check if your child has been diagnosed and/or treated for any of the following:

 ADHD/ADD
 Immune Disorder/HIV/AIDS
 Asthma/Respiratory Disease
 Autism Spectrum Disorder
 Cerebral Palsy
 Cancer/tumor
 Epilepsy/Seizures
 Cleft Lip/Palate
 Hepatitis/Liver Disease
 Diabetes
 Developmentally Delayed
 Sickle Cell Anemia/Trait
 Speech Disorder
 Eye Conditions/Vision Problems
 Hearing Impairment
 Heart Murmur/defect/surgery
 Tuberculosis
 Kidney Disease
 Sleep Apnea
 Hemophilia/Bleeding Disorder
 Anemia
 Metabolic Disorder
 Stomach/GI Disorders
 Acid Reflux
 Psychiatric Care
 Premature Birth
 Genetic Syndrome/Disorder
 Cold Sores/Canker Sores
 Eating Disorder
 Implants/Shunts/Pins
 Bone/Joint/Muscle Problems
 Other:

6. Has your child ever visited a dentist before? Yes No

If yes, please list the previous dentist and date of last visit:

7. Has your child experienced any unfavorable reaction from previous dental or medical care?
Yes No

If yes, please explain:

8. Does your child have a specific dental problem that needs attention? Yes No

If yes, please explain:

9. Has your child ever been hospitalized, sedated, and/or undergone surgery? Yes No

If yes, please explain:

10. Has your child ever received nitrous oxide (laughing gas), oral sedation or general anesthesia to complete dental work? If so, were there any complications? Yes No

If yes, please explain:

11. Has your child ever experienced dental trauma? Yes No

If yes, please explain:

Oral Habits

12. Does your child currently:

Breastfeed
Bottle feed
Thumb/finger suck
Use pacifier
Bite nails
Grind Teeth
Mouth breathe
Tongue thrust

13. How often does your child brush? AM only PM only AM and PM

14. Does your child floss? Yes No

15. Is assistance provided with the brushing and flossing? Yes No

16. Is fluoridated toothpaste used? Yes No

17. Does your child take a bottle or cup to bed? Yes No

18. Does your child receive:

Tap water
Well water
Bottled water
Fluoride rinse
Fluoride tablets/rinse

Consent for Dental Treatment

I am the parent and/or legal guardian of the patient and there are no court orders in effect preventing me from giving consent. I confirm that the information provided above is accurate to the best of my knowledge. I am aware that I must inform Growing Grins Pediatric Dentistry of any changed to my child’s medical history. I provide authorization for Growing Grins Pediatric Dentistry to perform any necessary dental services including, but not limited to, a comprehensive examination, cleanings, fluoride treatment, and any necessary dental treatment to maintain my child’s oral health. I have been advised that x-rays may be necessary to properly diagnose dental disease and to detect pathology. I have an expectation that risks and benefits for all dental treatment will be explained. I understand the most common dental complications include, not are not limited to, pain or discomfort during treatment, swelling, infection, bleeding, injury to adjacent teeth or surrounding tissues, development of a temporomandibular disorder, temporary or permanent numbness, and allergic reactions.

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