Health History

Child's Name:

Nickname:

Age:

Birthdate:

Gender:  Male Female

Address:

City:

Zip Code:

School:

Hobbies:

How did you hear about MooreKidsSmile Pediatric Dentistry:

Dental History

Is this the child's first dental visit?  Yes No - If no, please give Dentist's name and date of last visit:
Were x-rays taken?  Yes No

Are you aware of any dental problems from which your child suffers?  Yes - If yes, please explain: No

Does your child have any of the following habits?  Thumb or finger sucking Pacifier Bottle Teeth Grinding

How did your child react to previous dental visits?  Positive Negative

How do you expect your child to react to today's visit?  Positive Negative Unsure

Medical History

Has your child ever had a blood transfusion?  Yes No

What was the Date:

Are the child's immunization shots up to date?  Yes No

Has the child ever had surgery, or been in the hospital overnight?  Yes - If yes, please give date and explanation: No

Is the child taking any medications?  Yes No

Please list:

Does the child have any tubes, shunts or prostheses?  Yes - Is so, please explain: No

Has the child ever had any radiation therapy?  Yes - If so, please explain: No

Name of child's Pediatrician or Clinic:

AIDS/HIV Exposure:
 yes no

Diabetes Medication?
 yes no

Drug Allergies
 yes no

Food Allergies
 yes no

Epilepsy, Seizures Medication?
 yes no

Hepatitis or Liver Disease
 yes no

Asthma Medication?
 yes no

Learning Disability
 yes no

Autism
 yes no

Mental Retardation
 yes no

Behavioral Problems
 yes no

Tuberculosis exposure
 yes no

Blood Disorders/Anemia/Hemophilia/Sickle Cell Anemia/Other
 yes no

Heart Disease/Murmur/History Rheumatic Fever/Congenital Defect/Other
 yes no

Cancer
 yes no

Hearing Loss
 yes no

Cerebral Palsy
 yes no

Kidney Disease
 yes no

Chicken Pox
 yes no

Skin Rash
 yes no

Measles
 yes no

Pregnancy
 yes no

If Yes to any of the above, please explain and list medications.

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