Pediatric Health History Form

MEDICAL and DENTAL HISTORY

Child's Medical Dr. Dr.'s Phone Date of last complete physical examination?

Child's weight lbs. Height Is your child in good health? Currently under treatment of a physician for any reason?

Is your child receiving any medications or drugs? please list

Has your child ever been hospitalized, had surgery or been seriously ill? If so, describe

Any psychological, emotional or developmental problems you feel I should know about? (please explain)

Date of last dental visit For what reason? Name of last dentist

DOES YOUR CHILD CURRENTLY HAVE OR PREVIOUSLY HAD ANY OF THE FOLLOWING?

IF YES TO ANY ABOVE PLEASE EXPLAIN

I understand that it is my responsibility to inform Doctor of any changes in my child's medical status or health.

INFORMED CONSENT (please read completely)

I hereby authorize Doctor and his/her staff to perform all dental diagnostic procedures on my child including X-Rays, cleaning and topical fluoride treatment unless I have specifically made other arrangements in writing.

I understand that a plan of treatment will be presented BEFORE any treatment is performed and that I will have the opportunity to fully discuss with Doctor any alternatives to treatment including the use of any drugs, agents, or methods to be used. After accepting a mutually agreed upon treatment plan, as indicated by making an appointment for treatment, I CONSENT to the use of such methods and agents as may be indicated with such care. Agents may include, but are not limited to, local anesthetics commonly used in the practice of dentistry. Any drugs or sedative inhalants used wiII be discussed separately before using them unless they are used for life-saving purposes.

SIGNATURE DATE

PRINT last name Relationship to child

HISTORY SUMMARY: (For Doctor's Use) History Reviewed by Dr. SBE Prophylaxis Required Latex Allergy

Patient Validation: