Children's Dental & Medical Health History Form - Brooklyn Office Step 1 of 3 33% PATIENT INFORMATIONTo the parents/guardians of the patient: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat the patient.Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)Parent’s/Guardian’s Name:(Required) First Last Email(Required) Home PhoneCell PhoneWork PhoneMailing Address(Required)City(Required)State(Required)Zip(Required)Have you (the adult) or the patient (the child) had?Please select one of the options for your answer (Please bring this form to the receptionist right away if you marked “Yes” to any of these items.) A cough that’s lasted longer than three weeks A cough that produces blood Active Tuberculosis N/A PATIENT’S DENTAL HEALTH HISTORYWhat is the reason for your visit today?(Required)How would you describe the patient’s oral health?(Required) Excellent Good Fair Poor Does the patient currently have any dental pain or discomfort?(Required) Yes No If yes, where?(Required)Is this the patient’s first visit to a dentist?(Required) Yes No If no, when was the patient’s last dental exam?(Required)What was done at that appointment?(Required)When was the last time the patient had dental x-rays taken?(Required)Has the patient had any problem with dental treatment in the past?(Required) Yes No N/A If yes, please describe what happened:(Required)Has the patient had any problems with teeth coming in or losing teeth?(Required) Yes No N/A Does the patient use fluoride toothpaste when brushing teeth?(Required) Yes No N/A How often are the patient’s teeth brushed?(Required)time(s) per(Required)At what time(s) of day are the teeth brushed?(Required)Has the patient ever worn braces or other orthodontic appliances?(Required) Yes No N/A Has the patient ever had a serious injury to the head, mouth or teeth?(Required) Yes No N/A If yes, please describe what happened and when it happened(Required)Does the patient play any contact sports or participate in active recreational activities?(Required) Yes No N/A If yes, please describe those activities here(Required)Is your home water supply fluoridated?(Required) Yes No N/A What is the patient’s primary source of drinking water?(Required) Tap Bottled Filtered Well Does the patient take fluoride supplements?(Required) Yes No N/A Does/did the patient use a pacifier or suck his/her thumb or fingers?(Required) Yes No N/A At what age did the patient stop breastfeeding?At what age did the patient stop bottle feeding?Has the patient ever experienced any sleep-related breathing disorders?(Required) Mouth Breathing Snoring Trouble Breathing During Sleep N/A PATIENT’S MEDICAL HEALTH HISTORY & VACCINATION STATUSPlease list the name and phone number of the patient’s physician:Doctors Name(Required) First Last Phone(Required)Does the patient see any medical specialists?(Required) Yes No If Yes, Please explain(Required)Is the patient currently being treated for any condition(s) or illness(es)?(Required) Yes No N/A If yes, what is the illness and when did it start?(Required)Has the patient ever had a serious illness?(Required) Yes No N/A If yes, what is the illness and when did it start?(Required)Has the patient ever been hospitalized?(Required) Yes No N/A When and why?(Required)Has the patient ever been given a general anesthetic?(Required) Yes No N/A Has the patient ever had a blood transfusion?(Required) Yes No N/A Does the patient experience excessive bleeding when cut?(Required) Yes No N/A Has a physician or dentist ever suggested that the patient take antibiotics before seeing the dentist?(Required) Yes No N/A Doctor’s Name:(Required)If so, please explain why and provide the name of the doctor making that recommendation First Last Phone(Required)Has the patient been diagnosed with any physical, developmental, mental or emotional conditions?(Required) Yes No N/A If yes, please explain(Required)Does the patient have any genetic (inherited) conditions?.(Required) Yes No N/A If yes, please explain(Required)Does the patient have any speech difficulties?(Required) Yes No N/A If yes, please explain(Required)How would you describe the patient’s eating habits?(Required)Is the patient up-to-date with immunizations related to patienthood diseases (tetanus, measles, mumps, etc.)?(Required) Yes No If of the appropriate age, what is the patient’s Human papillomavirus/HPV immunization status?(Required) Immunized Not immunized Please check the box in front of any health conditions or issues the patient has now or has had in the past: ADD/ADHD Alcohol/Drugs Anemia Arthritis Asthma Bladder problems Bleeding disorders Bone/Joint issues Cancer Cerebral Palsy Chicken Pox Chronic sinusitis Diabetes Ear aches Epilepsy Fainting Growth problems Hearing problems Heart Issue Heart Murmur Hepatitis HIV/AIDS Immunizations Kidney problems Liver problems Measles Mononucleosis Mumps Pregnancy (teens) Rheumatic Fever Seizures Sexually transmitted infection (STI) Sickle Cell Anemia Thyroid issues Tobacco/Vaping Tuberculosis Other MEDICATIONS & ALLERGIESIs the patient currently taking any prescription medications, vitamins, supplements and/or over-the-counter medications?(Required) Yes No N/A If yes, please list them here:(Required)Is the patient allergic to any antibiotics (penicillin), pain medications (acetaminophen, ibuprofen, opioids) or any other medications?(Required) Yes No N/A If yes, please list those medications and what happened when the patient took them(Required)Does the patient have other allergies, such as to latex, metals, certain foods, animals, plants, etc.?.(Required) Yes No N/A If yes, please describe the allergy and the reaction(Required)NOTE: I understand that it’s important for both the dentist and the patient or his/her parent/guardian to talk honestly about the patient’s health before dental treatment starts. I have answered all of the questions above completely and accurately. I understand that the dentist and his/her staff need this information so the patient receives the right kind of dental care. I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.The dentist and I have talked about any questions I had about this form. I will not hold the dentist, or any other member of his/her staff, responsible for anything they did, or didn’t do, because of any mistakes I might have made in filling out this form.Signature of Parent/Legal Guardian:Date MM slash DD slash YYYY CAPTCHA
