Medical History

Patient Name	{field:patient_name_1722010115936}
DOB	{field:dob_1722016553297}
Patient Address	{field:textbox_1722425633430}
City	{field:city_1722457968953}
State	{field:liststate_1722457996654}	Zip	{field:zip_1722458001864}
School Child Attends	{field:school_child_attends_1722449911995}
1. Is your child being treated by a physician at this time?	{field:1_is_your_child_being_treated_by_a_physician_at_this_time_1722425769305}	If yes, explain:	{field:if_yes_please_explain_1722012768145}
2. Does your child have allergies to any medications that you are aware of?	{field:2_does_your_child_have_allergies_to_any_medications_that_you_are_aware_of_1722425776774}	If yes, list allergies:	{field:if_yes_please_list_all_allergies_1722012871602}
3. Is your child taking any medications (prescription or over the counter)?	{field:3_is_your_child_taking_any_medications_prescription_or_over_the_counter_1722425785553}	If yes, list medications:	{field:if_yes_please_list_1722012932285}
4. Has your child ever been hospitalized, had surgery, or a significant injury?	{field:4_has_your_child_ever_been_hospitalized_had_surgery_or_a_significant_injury_1722425793321}	If yes, explain:	{field:if_yes_please_explain_1722012970373}
5. Is your child up to date on immunizations?	{field:5_is_your_child_up_to_date_on_immunizations_1722425800490}
6. Has a physician ever said that your child needs pre-med before dental treatment?	{field:6_has_a_physician_ever_said_that_your_child_needs_pre-med_before_dental_treatment_1722425808277}	Primary physician name and phone number:	{field:primary_physician_name_and_phone_number_1722013041522}
7. Is there anything that we should know about your child’s medical or dental health?	{field:7_is_there_anything_that_we_should_know_about_your_child_s_medical_or_dental_health_1722425816459}	If yes, please explain:	{field:if_yes_please_explain_1722362532903}
Dental questions:
1. Do you have any concerns about your child’s dental health?	{field:1_do_you_have_any_concerns_about_your_child_s_dental_health_1722425466276}
2. Has your child ever been examined or treated by another dentist?	{field:2_has_your_child_ever_been_examined_or_treated_by_another_dentist_1722013469432}	If yes, date of last dental visit (if known):	{field:if_yes_date_of_last_dental_visit_if_known_1722013521010}
3. Has your child ever had braces/ spacers/ or other appliances?	{field:3_has_your_child_ever_had_braces_spacers_or_other_appliances_1722014505296}	If yes, explain:	{field:if_yes_explain_1722014525326}
Dental History
Cavities	{field:cavities_1722014620836}	Injury to teeth or gums?	{field:injury_to_teeth_or_gums_1722014731543}
Mouth sores or fever blisters?	{field:mouth_sores_or_fever_blisters_1722014744222}	Clenching or grinding teeth?	{field:clenching_or_grinding_teeth_1722014762275}
Sucking habits after 1 year of age?	{field:sucking_habits_after_1_year_of_age_1722014776472}	Excessive gagging?	{field:excessive_gagging_1722014790511}
Dental Habits
How often does your child brush their teeth per day?	{field:how_often_does_your_child_brush_their_teeth_per_day_1722016754272}	Does someone help your child brush?	{field:does_someone_help_your_child_brush_1722454162266}
How often does your child floss their teeth?	{field:how_often_does_your_child_floss_their_teeth_1722016865513}	Does someone help your child floss?	{field:does_someone_help_your_child_floss_1722454183303}
Personal Data
Your Name	{field:your_name_1722016973262}
Relationship to the Patient	{field:relationship_to_the_patient_1722016992031}
Telephone number to reach you if we have questions:	{field:telephone_number_to_reach_you_if_we_have_questions_1722017071852}	Date Completed	{field:date_completed_1722366720832}

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