Professional Documents
Culture Documents
Has your child ever had any of the following medical problems? If yes, circle and please explain.
Dental History
What is the reason for today’s visit?_______________________________________________________________________
Yes No Has your child ever been seen by a dentist before? If yes, name and date_______________________________________
Yes No Do you expect your child to be uncooperative?
Yes No Has your child ever had an unfavorable dental experience?
Yes No Does your child drink unfluoridated water?
Yes No Does your child take fluoride supplements?
Yes No Have there been any injuries to your child’s face, mouth or teeth?_____________________________________________
Yes No Does your child eat toothpaste?
Yes No Does your child suck his/her thumb, finger(s), pacifier, blanket, bite nails, etc? (circle if yes)
Yes No Have your child’s tonsils/adenoids been removed?
Has there been any change in the patient’s health since the last dental appointment? Yes No
If yes, please describe________________________________________________________________________
___________________________________________________________________________________________
Is patient taking any new medicines? Yes No
Please list__________________________________________________________________________________
I have reviewed the medical, dental and medication information on the reverse side of this form and have noted any
changes above.
Signed_____________________________________________________ Date_____________________________
Has there been any change in the patient’s health since the last dental appointment? Yes No
If yes, please describe________________________________________________________________________
___________________________________________________________________________________________
Is patient taking any new medicines? Yes No
Please list__________________________________________________________________________________
I have reviewed the medical, dental and medication information on the reverse side of this form and have noted any
changes above.
Signed_____________________________________________________ Date_____________________________
Has there been any change in the patient’s health since the last dental appointment? Yes No
If yes, please describe________________________________________________________________________
___________________________________________________________________________________________
Is patient taking any new medicines? Yes No
Please list__________________________________________________________________________________
I have reviewed the medical, dental and medication information on the reverse side of this form and have noted any
changes above.
Signed_____________________________________________________ Date_____________________________