Pediatric Special Needs Dental Medical History Form
Patient Information
Child's Name
Date of Birth
Gender
Female
Male
Other
Parent/Guardian Name
Contact Number
Email
Address
Medical Information
Primary Physician
Diagnosis/Special Needs
Medications (include dosages)
Allergies (medications, foods, etc.)
Has your child ever been hospitalized or had surgery?
No
Yes
If yes, please explain
Other physicians/specialists involved in care
Dental Information
Previous Dentist
Date of Last Visit
Current Dental Concerns
Has the child had difficulty with previous dental visits?
No
Yes
If yes, please explain
Oral Habits (thumb sucking, grinding, etc.)
Additional Information
Behavioral Techniques or Supports Used
Preferred Methods of Communication
Mobility/Accessibility Needs
Other Information or Concerns
Parent/Guardian Signature
Date