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Medical Dental History Form
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Medical Dental History Form
MEDICAL ALERT / D.D.S. USE ONLY
S.B.E. PRECAUTIONS
BLOOD/BODY FLUID PRECAUTIONS
ALLERGIES
RESTRICTIONS TO CARE
OTHER
CHILD INFORMATION
First Name
*
Last Name
*
Gender
*
M
F
Age
*
Date
*
Medical Diagnosis and/or Handicapping condition
Card
Seiz
Ortho
Urol
Cleft P
Cyst F
Hemo
M.R.
E.D.
Blind
Deaf
M.H.
A. PRETREATMENT MEDICAL EVALUATION
1. General state of health
EXCELLENT
GOOD
FAIR
POOR
2. Under physician care within last 6 months
NO
YES
Notes (if any)
3. Drugs or medications within last 6 months (If yes, list In Section D)
NO
YES
Notes (if any)
4. Serious Illness or operation
NO
YES
Notes (if any)
5. Exceptional / handicapped
NO
YES
Notes (if any)
6. Allergies / Allergy to Drugs Penicillin, local anesthesia
NO
YES
Notes (if any)
7. Pregnant
NO
YES
Notes (if any)
8. Hepatitis /Jaundice
NO
YES
Notes (if any)
9. Heart Disease or heart murmur
NO
YES
Notes (if any)
10. Rheumatic Fever
NO
YES
Notes (if any)
11. Respiratory Problems
NO
YES
Notes (if any)
12. Frequent colds, sore.throats, sinus trouble
NO
YES
Notes (if any)
13. Blood disease
NO
YES
Notes (if any)
14. Prolonged bleeding after tooth extraction or out
NO
YES
Notes (if any)
15. Radiation therapy (x-ray therapy)
NO
YES
Notes (if any)
16. Convulsions / seizures
NO
YES
Notes (if any)
17. Nervous system disease
NO
YES
Notes (if any)
18. Endocrine disease
NO
YES
Notes (if any)
18. Endocrine disease
NO
YES
Notes (if any)
20. Diabetes
NO
YES
Notes (if any)
21. Gastrointestinal (stomach or intestinal problem)
NO
YES
Notes (if any)
22. Kidney, bladder, genitourinary problems
NO
YES
Notes (if any)
23. History of T.B., diabetes, bleeding or any inheritable problems In family
NO
YES
Notes (if any)
24. Immunizations up to date
NO
YES
Notes (if any)
25. Head, neck and / or jaw pain
NO
YES
Notes (if any)
26. History of serious family Illness
NO
YES
Notes (if any)
27. Skin, bone, hair problems
NO
YES
Notes (if any)
28. Other problems
NO
YES
Notes (if any)
29. Exposure to Hepatitis B
NO
YES
Notes (if any)
30. Exposure to H.I.V
NO
YES
Notes (if any)
31. Previous Blood Transfusions
NO
YES
Notes (if any)
B. SOCIAL HISTORY
Names Of Brothers & Sisters
Patient Adopted
NO
YES
Birth Order
Who Provides Home Care For Child ( Name Of School/ Day Care Center)
Favourite Person
Favourite Toy / Game
Favourite Pet
Favourite T.V. Show
Others
D.D.S. USE ONLY
MEDICAL CONSULTANT REQUIRED PRIOR TO TREATMENT
NOTIFIED
DATE:
COMPLETED
DATE:
C. DENTAL HISTORY
Chief Complaint
History Of Dental Pain
NO
YES
History Of Facial Trauma
NO
YES
Date Of Last Dental Visit
By Whom
Reaction To Last Dental Visit
Services Provided At Last Dental Visit
Age At First Dental Visit
Frequency Of Dental Visits
Comments
D. MEDICAL HISTORY
Current Medications
I HEREBY CERTIFY TO THE ACCURACY OF THE ABOVE HISTORIES
Parent/Guardian Name
*
I agree
*
NO
YES
Date
*
2024-05-11
Reviewed By Resident/D.A.
Reviewed By Primary D.D.S
Date
Date
OFFICE USE ONLY
SUMMARY OF MEDICAL EVALUATIONS & DESCRIPTION OF ANY ABNORMALITIES OR POSITIVE FINDINGS
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