PLEASE COMPLETE ENTIRE FORM

Patient Name
Child's Physician (Office and Doctor's name)
Are Immunizations Up to Date? YesNo Is Your Child in General Good Health? YesNo

 

Has Your Child Ever been Hospitalized of Had Any Kind of Surgery? YesNo
If so, Please explain and give date.

 

Is Your Child Allergic to any Antibiotics/Drugs? YesNo
If Yes, Please Explain What and What Type of Reaction.

 

Is Your Child Allergic to Anything Else (i.e: latex, dyes, etc)? YesNo
If Yes, Please Explain What and What Type of Reaction.

 

Please check yes or no if your child has been diagnosed or treated for any of the following:

ASTHMA
 YesNo HEART DISEASE YesNo
BLEEDING DISORDERS YesNo ENIRONMENTAL/SEASONAL ALLERGIES
 YesNo
LIVER DISEASE YesNo ANEMIA YesNo
ADHD/ADD
 YesNo KIDNEY DISEASE YesNo
SEIZURES/EPILEPSY YesNo AUTISM SPECTRUM DISORDER
 YesNo
CANCERS/TUMORS YesNo DIABETES YesNo
DOWN’S SYNDROME
 YesNo PERSONALITY/SOCIAL DISORDERS YesNo
HEPATITIS YesNo CEREBRAL PALSY
 YesNo
VISION PROBLEMS YesNo AIDS/HIV YesNo
CLEFT LIP/PALATE
 YesNo ACID REFLUX/GERD YesNo
SPEECH/HEARING DIFFICULTIES YesNo MENTAL DELAYS
 YesNo
PHYSICAL DELAYS YesNo EATING DISORDERS YesNo
NEUROLOGICAL PROBLEMS
 YesNo    

 

Please provide details if you answered yes to anything above (i.e: type, etc).

Please list anything else not listed above and elaborate.

Is There Any Significant Family History Of Diseases/Oral Cancers? YesNo

If yes, please explain.

Is Your Child Currently Taking Any Medications? YesNo

If yes, please explain.

Drug Name Dosage/Frequency Reason
Drug Name Dosage/Frequency Reason

Dental History

Are There Any Specific Concerns/Questions Regarding Your Child’s Mouth/Teeth?_
Has Your Child Ever Suffered Any Injuries to The Mouth or Teeth? YesNo

If yes, please explain.

Has Your Child Ever Seen a Dentist? YesNo
If So, Name of Dentist and Date of Last Exam

 

Is There Anything You Can Tell Us To Help “Connect” With Your Child?

Does your child currently do any of the following? (Please checkall that apply):

Breast FeedBottle FeedGrindThumb/Finger SuckUse a PacifierNONE

What Type of Water Is Present In Your Home?

Filtered Water (from tap or fridge)Reverse OsmosisWell WaterBottled Water

Does Your Child Use Fluoride Toothpaste? YesNo

Any Other FormsOf Fluoride? (Rinse,Vitamins, etc.)

 

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