Has the child had a serious or difficult problem associated with previous dental work?

Please comment on the following:

Lip Sucking/Biting:

Yes No

Nursing/Bottle Habits:

Yes No

Thumb/Finger Sucking:

Yes No

Is the patient’s water fluoridated:

Yes No

Is the patient taking fluoride supplements:

Yes No

Does the patient brush teeth daily:

Yes No

Does the patient floss teeth daily:

Yes No

Child’s Allergies (include date noted if known):

Child’s Medications (include dose if known):

Please discuss any serious Medical conditions:

Please discuss any past hospitalizations or operations:

Patient’s Physician:

Has the patient ever had any of the following conditions:

Heart disease / Murmur

Yes No

Kidney / Liver problems

Yes No

High blood pressure

Yes No

Low blood pressure

Yes No

Heartburn (reflux)

Yes No

Abnormal bleeding

Yes No

Lung problems

Yes No

Sinus problems

Yes No

Hearing impairment

Yes No

Pain in jaw (TMJ/TMD)

Yes No

Autism Spectrum Disorder

Yes No

Developmental delays

Yes No

Congenital Birth Defects

Yes No

Rheumatic/Scarlet Fever

Yes No

Latex allergy

Yes No

Penicillin allergy

Yes No

Amoxicillin allergy

Yes No

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services that my child may need.

Patient Form

Patient

Responsible Party

Primary Insurance

Dental History

Medical History

only pediatric dental specific office in Atlantic County