Medical HistoryPatient Name :* First Last Date of Birth :* Month Day Year Name of person completing questionnaire :* First Last Relationship :* Reaon for todays visit :* Establish Care (New Patient) Emergency Referral Referred By : AllergiesDo you have allergies?* Yes No What allergies do you have? Aspirin Acetaminophen (Tylenol) Antibiotics (ex. Penicillin/Amoxicillin, Cephalosporin, Erythromycin, etc.) Dental Anesthetics Ibuprofen (Advil) Latex Metals Other List other allergies : Please explain type of symptoms of reaction : Immunizations/vaccinations up to date?* Yes No If no, please explain : Medical HistoryDoes your child have (or has he/she ever had) any of the following conditions? Please select all that apply.* Anaphylactic Reaction ADHD AIDS/HIV Anemia Asthma Autism Bleeding Disorder (ex. Hemophilia, vWD) Blood Transfusion Blood Pressure Issues Cancer Cerebral Palsy Chemotherapy/Radiation Treatment Cleft Lip / Cleft Palate Developmental Delay Diabetes Heart Murmur, innocent Heart Defect Hepatitis Intellectual Delay Mouth sores Obsessive Compulsive Disorder (OCD) Oppositional Defiant Disorder (ODD) Other Disability/Syndrome Pregnant (females) Premature Birth- Gestational Seizures (ex. Epilepsy) Sickle Cell Anemia Seasonal allergies Special Diet Speech Delay Thalassemia Tobacco Use Previous trauma to head / face NO to all, child is HEALTHY What was the cause of the Anaphylactic Reaction? Is your child's asthma : Mild Moderate Severe Date inhaler was last used : MM slash DD slash YYYY Asthma is caused by : Is your child's autism : Mild Moderate Severe Bleeding Disorder Type : Blood Transfusion Dates : Blood Pressure : High Low Type of Cancer : Date of Diagnosis : MM slash DD slash YYYY Is your child : In therapy In Remission Does your child have a port present requiring antibiotic premedication? Yes No Is your child's Cerebral Palsy : Mild Moderate Severe Is your child's Chemotherapy/Radiation Treatment : Past Present Date(s) of child's Chemotherapy/Radiation Treatment : Is your child's Development Delay : Mild Moderate Severe Is your child's Diabetes : Type I Type II Last HbA1C : Date Taken : Your child's Heart Defect Type : Did your child's Heart Defect require repair? Yes No Date of your child's Heart Defect repair : MM slash DD slash YYYY Does your child's Heart Defect require antibiotic premedication? Yes No Hepatitis Type : A B C Child's Intellectual Delay : Mild Moderate Severe What types of Mouth Sores does your child get? Canker Sores Cold Sores Ulcers What is the frequency of Mouth Sores : Occassionally Monthly Weekly What Other Disability/Syndrome does your child have? Gestational Age at Birth : Date of child's last seizure : MM slash DD slash YYYY Does your child carry rescue medication? Yes No Frequency of child's seizures : MM slash DD slash YYYY Please explain your child's special diet : Is your child G-tube fed? Yes No What is your child's % nutrient intake through G-tube : Rate your child's Speech Delay : Mild Moderate Severe Is your child's Thalassemia : Alpha Beta Does your child have an Individualized Education Program (IEP) at school?* Yes No What percent of time does your child spend in regular classroom? Any other condition not listed here (please specify) : Additional Medical HistoryDoes your child have (or has he/she ever had) any of the following additional conditions? Please select all that apply.* Cardiac Problems Gastrointestinal Problems Hearing/Speech Problems Kidney Problems Liver Problems Muscular Problems Respiratory Problems Thyroid Problems Vision Problems NO to all, child is HEALTHY Please describe your child's Cardiac Problems : Please describe your child's Gastrointestinal Problems : Please describe your child's Hearing/Speech Problems : Please describe your child's Kidney Problems : Please describe your child's Liver Problems : Please describe your child's Muscular Problems : Please describe your child's Respitory Problems : Please describe your child's Thyroid Problems : Please describe your child's Vision Problems : Has your child ever been hospitalized?* Yes No Date & reason child was hospitalized : Has your child ever had surgery?* Yes No Date & reason child had surgery : Any complications with anesthetic or recovery : Please list any condition(s) not listed above :Medical Provider/Primary Care Physician InformationPrimary Care Physician :* Primary Care Physician Practice Name :* Primary Care Physician Phone :*Primary Physician Practice Address : Street Address City State ZIP / Postal Code Medical SpecialistsDoes/did your child recieve care from any medical specialist?* Yes No Physician/Specialist’s Name : Specialty (ex. Cardiology) : Hospital Name : Hospital Location City State ZIP / Postal Code Does/did your child recieve care from another medical specialist?* Yes No Physician/Specialist’s Name : Specialty (ex. Cardiology) : Hospital Name : Hospital Location City State ZIP / Postal Code Does/did your child recieve care from another medical specialist?* Yes No Physician/Specialist’s Name : Specialty (ex. Cardiology) : Hospital Name : Hospital Location City State ZIP / Postal Code Does/did your child recieve care from another medical specialist?* Yes No Physician/Specialist’s Name : Specialty (ex. Cardiology) : Hospital Name : Hospital Location City State ZIP / Postal Code MedicationsList all Medications - Dosage - What is the medication taken for? Children's Dental CentreWe are excited to be your pediatric dentist!Schedule Your Appointment Now!
