Medical History Child Medical & Dental History Form Name * First Last * Last DOB Age Email * Phone 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? Yes No Active Tuberculosis Persistent cough greater than a 3 week duration. Cough that produces blood. If you answer yes to any of these items above, please stop and return this form to the receptionist. Has your child had any history of, difficulty with , or diagnosis of any of the following: [please check appropriate box(es)] Heart Condition Asthma Latex Allergy Blood Disease Diabetes Handicap/Disabilities Tuberculosis Skin Disorders Rheumatic Fever Hepatitis Lung Disorder Nose/Throat Disorder Cancer/Tumors HIV+/AIDS Stomach Problems Liver Problems Kidney Problems Ear Problems/Tubes Speech Problems Vision Problems Epilepsy/Siezures ADD/ADHD Mental/Emotional Disorders OtherOther Please explain any medical condition that your child has:Please explain any medical condition that your child has: Child’s Physician: Phone Medical History: Is the child taking any medication at this time? Yes No Please list:Please list: Is the child allergic to any medications, i.e. penicillin, or other drugs? Yes No Please list:Please list: Is the child allergic to any medications, i.e. penicillin, or other drugs? Yes No How would you describe the child’s eating habits? Has the child ever been seriously ill? Yes No When:When: Please explain:Please explain: Has the child ever been hospitalized? Yes No Please explain:Please explain: Does the child have a history of any other illnesses? Yes No Please explain:Please explain: Has the child ever received a general anesthetic? Yes No Does the child have any inherited problems? Yes No Has the child ever had a blood transfusion? Yes No Does the child experience excessive bleeding when cut? . Yes No Is the child currently being treated for any illness? Yes No Dental History Is this the child’s first visit to the dentist? If not, what was the date of the last dentist visit? Yes No Date:Date: Has the child had any problem(s) with dental treatment in the past? . Yes No Has the child ever had dental radiographs (x-rays) exposed? Yes No Has the child ever suffered any injuries to the mouth, head, or teeth? Yes No Has the child had any orthodontic treatment? Yes No What type of water does your child drink? City water Well water Bottled water Does the child take fluoride supplements? Yes No Pills or Drops?Pills or Drops? Dosage:Dosage: mgmg Is fluoride toothpaste used? Yes No How many times are the child’s teeth brushed per day? Please state # of days When are they brushed?When are they brushed? Does the child suck his/her thumb, fingers, or pacifier? Yes No Is the child bottle feeding? If no, at what age was it discontinued? Yes No 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. Parent’s/Guardian’s Signature: Date If you are human, leave this field blank. Submit