Pediatric Dental Medical History Form
Patient Information
Child's Name
Date of Birth
Gender
Female
Male
Other
Address
Parent/Guardian Name
Phone Number
Email
Medical History
Pediatrician's Name
Pediatrician's Phone
Does your child have any medical conditions?
Has your child ever had any of the following? (Check all that apply)
Asthma
Diabetes
Allergies
Heart Condition
Epilepsy / Seizures
Other
List any medications your child is currently taking
List any allergies your child has
Dental History
What is the reason for today's visit?
Has your child had any dental injuries?
No
Yes
If yes, please describe
Previous Dentist
Date of Last Dental Visit
Signature
Parent/Guardian Signature
Date