Medical History

Child Medical & Dental History Form

A Note to Our Parents:
Although dentists primarily treat areas in and around the mouth, it is a part of the entire body.
Health problems that your child may have or medications that your child may be taking could have an important interrelationship with the care that he/she will be receiving. Thank you for answering the questions. Your answers are for our records and will be
considered confidential.

Have you (parent or guardian) or the patient had any of the following diseases or problems?

If you answer yes to any of these items above, please stop and return this form to the

Has your child had any history of, difficulty with , or diagnosis of any of the following: [please check appropriate box(es)]

Medical History:

Is the child taking any medication at this time?
Is the child allergic to any medications, i.e. penicillin, or other drugs?
Is the child allergic to any medications, i.e. penicillin, or other drugs?
Has the child ever been seriously ill?
Has the child ever been hospitalized?
Does the child have a history of any other illnesses?
Has the child ever received a general anesthetic?
Does the child have any inherited problems?
Has the child ever had a blood transfusion?
Does the child experience excessive bleeding when cut? .
Is the child currently being treated for any illness?

Dental History

Is this the child’s first visit to the dentist? If not, what was the date of the last dentist visit?
Has the child had any problem(s) with dental treatment in the past? .
Has the child ever had dental radiographs (x-rays) exposed?
Has the child ever suffered any injuries to the mouth, head, or teeth?
Has the child had any orthodontic treatment?
What type of water does your child drink?
Does the child take fluoride supplements?
Is fluoride toothpaste used?
How many times are the child’s teeth brushed per day?
Does the child suck his/her thumb, fingers, or pacifier?
Is the child bottle feeding? If no, at what age was it discontinued?

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been an- swered to my satisfaction. I will not hold the Dr. Kuwabara, or any other member of his staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.