Medical History Form

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Date of birth: *

Age:

Male Female

Name of Child's Physician?:

Child Physician's Phone Number:

Any problems/complications durning pregnancy/delivery? If yes, please explain: *

Does your child have any health problems? If yes, please explain: *

Has your child been diagnosed with any medical conditions? If yes, please explain: *

Does your child have any allergies? If yes, please explain: *

Has your child ever been hospitalized? If yes, please explain (For & When): *

Has you child ever had surgery? If yes, please explain (For & When): *

Is your child taking any medication? If yes, please list: *

Are your child's immunizations up to date?: *

AIDS/HIV Positive

Diabetes

Hepatitis A/B/C

ADHD/ADD

Down Syndrome

Liver/Kidney Disease

Arthritis

Ear Infection

Leukemia

Asthma

Emotional Problems

Prolonged Bleeding

Autism

Endocrine Problems

Rheumatic Fever

Blood Problems

Epilepsy Seizures

Speech Problems

Bronchitis

Eye Problems

Tonsillitis

Cancer

Hearing Problems

Tuberculosis

Cerebral Palsy

Heart Problems

Thyroid Disease

Main reason for today's visit?:

How often are the child's teeth brushed?

1x/day

2x/day

Every Other Day

Not Regularly

How often are the child's teeth being flossed?

1x/day

2x/day

Every Other Day

Not Regularly

Who does the brushing and flossing?

Parent

Child

Half/Half

None

Fluoride Use?:

Rx by MD/DMD

in H2O

Toothpaste

Rinse

None

When was your child weaned off nursing/bottle?

6 Months

12 Months

24 Months

Still Use

Does your child have any oral habits?

Thumb/Finger

Binky

Mouth Breather

Grinding

History of Dental Trauma? If yes, please explain:

How would you rate mother's oral health?

Excellent

Good

Fair

Poor

I don't know

How would you rate father's oral health?

Excellent

Good

Fair

Poor

I don't know

How would you rate your child's candy consumption? (candy, juice, etc)

Low

Average

High

Is there any additional medical/dental information you may want the entists at Jacobsen Pediatric Dentistry to know?

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Medical History Form

Contact Information

Medical History