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Child Patient Medical History
Fields marked * are required.
Title*
Mr
Mrs
Miss
Ms
Patients Name*
Date of Birth*
Address*
Is your child currently on any medication *
Yes
No
Please list
Is your child under the care of a Medical Practitioner *
Yes
No
Does your child have any allergies *
Yes
No
Please list
General Dentist/School Dentist Name*
Dental Practice*
When was your last dental check-up*
Less then 6mths ago
6-12mths ago
12-24mths
More then 24mths
Medical History
Please tick if your child has had any of the following *
A heart disorder/Murmur
Bleeding Disorder
Rheumatic Fever
Diabetes
Asthma
Tonsils removed
Thyroid Problem
Attention Deficit Disorder
Adenoids removed
Aids/related disease
Hepatitis
Anxiety
Dental History
Please tick if you have any of the following*
Fluoride
Baby Teeth Extracted
Filling, Caps or Crowns
Root Canal Treatment
Permanent Teeth Extracted (including wisdom)
Chipped or Injured Teeth
Breathe predominantly through the mouth
Periodontal (gum) Disease
Teeth not Appeared
Suck/ed Thumb or Finger
Any other illness/disability not listed above: *
Yes
No
Please list
Has your child had any jaw pain or clicking *
Yes
No
Please list
Has your child had any speech therapy *
Yes
No
Please list
Has your child had any recent rapid growth *
Yes
No
Please list
Is there any Family dental traits *
Yes
No
Please list
What is your main concern in seeking this appointment *
How did you hear about us *
Family
Friends
Newspaper
School Newsletter
Website
Google
Facebook
Dental referral
Other
Parent/Guardian contact #1
Name*
Relationship to child*
Address*
Contact number/s*
Email*
Parent/Guardian contact #2
Name
Relationship to child
Address
Contact number/s
Email
Person completing this form*
Relationship to patient *
Date*
Signature
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