Kids Dental & Medical History FormIf you have any questions, please call our office at (204) 837-4517. What is the reason for your child's visit today? * Please answer YES or NO to the following: 1. Is this your child's first visit to the dentist? * Yes No If no, previous dentist: Date of last visit: 2. Has your child had any problems with previous dental care? * Yes No 3. Do you expect your child to cooperate for dental treatment? * Yes No 4. Have there been any injuries to your child's teeth? (falls, chips, etc) * Yes No If yes, please describe: 5. Is your child currently undergoing or had previous orthodontic treatment? * Yes No If so, with whom? And is it current or previous? MEDICAL HISTORY Name of paediatrician/family physician: * Is your child currently taking any medications? If yes, please list. * Does your child have any allergies? If yes, please list. * Has your child ever reacted poorly to medication or anesthesia? If yes, please explain. * Has your child ever been hospitalized? If yes, please explain. * Does your child have or ever been diagnosed with any of the following conditions? * ADD/ADHD Cancer Anaemia Anxiety Asthma Autism Bleeding disorder Eye problems Cerebral Palsy Cleft lip/palate Developmental delays Kidney disease Epilepsy Rheumatic fever Hearing loss Heart disease Hepatitis Liver diseaase Diabetes Seizures Sickle cell anemia Speech problems None of the above Is there anything else we should know about your child's health or medical conditions? Parent/Guardian Signature: * Date: * Thank you!
