Patient Name *

First Name

Last Name

Please provide name and number of your child's pediatrician AND any other doctor he/she is seeing. *

Yes

No

Has your child ever been hospitalized or had a major operation? *

Yes

No

Is your child on a special diet? *

Yes

No

Is your child allergic to any of the following?

Aspirin

Latex

Acrylic

Penicillin

Sulfa Drugs

Local Dental Anesthetics

Codeine

Demerol or Phenergan

Metal

Valium

Other Allergies (environmental/nuts/animals) *

Yes

No

Is your child taking any medications, inhalers, vitamins, pills, or drugs? *

Yes

No

AIDS/HIV Positive *

Yes

No

Diabetes *

Yes

No

Hepatitis B or C *

Yes

No

Rheumatic Fever *

Yes

No

Epilepsy or Seizures *

Yes

No

Excessive Bleeding *

Yes

No

Excessive Thirst *

Yes

No

Fainting Spells/Dizziness *

Yes

No

Frequent Cough *

Yes

No

Frequent Diarrhea *

Yes

No

Frequent Headaches *

Yes

No

Low Blood Pressure *

Yes

No

Thyroid Disease *

Yes

No

Tonsillitis *

Yes

No

Cold Sores/Fever Blisters *

Yes

No

Congenital Heart Disorder *

Yes

No

Psychiatric Care *

Yes

No

Cortisone Medicine *

Yes

No

Hepatitis A *

Yes

No

Renal Dialysis *

Yes

No

High Blood Pressure *

Yes

No

High Cholesterol *

Yes

No

Hives or Rash *

Yes

No

Hypoglycemia *

Yes

No

Irregular Heartbeat *

Yes

No

Kidney Problems *

Yes

No

Leukemia *

Yes

No

Liver Disease *

Yes

No

Cancer *

Yes

No

Chemotherapy *

Yes

No

Heart Attack/Failure *

Yes

No

Heart Murmur *

Yes

No

Parathyroid Disease *

Yes

No

ADD/ADHD *

Yes

No

Hemophilia *

Yes

No

Recent Weight Loss *

Yes

No

Anemia *

Yes

No

Rheumatism *

Yes

No

Scarlet Fever *

Yes

No

Shingles *

Yes

No

Sickle Cell Disease *

Yes

No

Sinus Trouble *

Yes

No

Spina Bifida *

Yes

No

Stomach/Intestinal Disease *

Yes

No

Stroke *

Yes

No

Glaucoma *

Yes

No

Hay Fever *

Yes

No

Osteoporosis *

Yes

No

Autism Spectrum *

Yes

No

Ulcers *

Yes

No

Jaundice (not a birth) *

Yes

No

Radiation Treatments *

Yes

No

Anaphylaxis *

Yes

No

Cold Sores/Fever Blisters *

Yes

No

Arthritis/Gout *

Yes

No

Artificial Heart Valve *

Yes

No

Artificial Joint *

Yes

No

Asthma *

Yes

No

Blood Disease *

Yes

No

Blood Transfusion *

Yes

No

Breathing Problems *

Yes

No

Bruise Easily *

Yes

No

Lung Disease *

Yes

No

Mitral Valve Prolapse *

Yes

No

Tuberculosis *

Yes

No

Tumors or Growths *

Yes

No

Heart Trouble/Disease *

Yes

No

Pregnant *

Yes

No

Has your child ever had any serious illness not listed above? *

Yes

No

Has your child ever had any "bad" dental experience in the past? *

Yes

No

Has your child experienced any complications following dental treatment? *

Yes

No

Has your child experienced prolonged bleeding following dental treatment? *

Yes

No

Has your child experienced any clicking or pain in jaw joint? *

Yes

No

Do you have family history of jaw surgery, missing teeth, or other dental issues? *

Yes

No

Has your child had any dental trauma or injury to jaw or teeth? *

Yes

No

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. *

Signature of Patient, Parent or Guardian:

First Name

Last Name