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Pediatric Dental Center of Mansfield, PC

Medical History

Child's Full Name: Nickname: Date of birth:
Gender: Male Female Adopted: Yes No
Home Address:
City: State: Zip:
Home Phone: Cell Phone: Email:
School: Grade: Home Schooled:
How did you hear about us (who referred you here)?
Favorite Toy/Game:
List common snacks your child eats daily:
Does your child take a fluoride supplements (with or without vitamins): Yes No
Has your child ever had trauma to the mouth or teeth: Yes No If yes, please describe:
Does your child have a thumb, finger or pacifier habit: Yes No If yes, which one:
Does your child drink juice or milk at bedtime: Yes No
List siblings name and date of births:
Mother's Full Name: Social security #
Employer: Occupation Business Phone:
Father's Full Name: Social security #
Employer: Occupation Business Phone:

Dental Insurance Information

Subscribers Name: Subscribers ID
Subscribers Date of Birth: Employer:
Insurance Company: Group ID:
Address: City: State:
Zip Code: Phone Number:

Dental History

Previous Dentist Name: Last Visit:
Address: Phone Number:
Reason for today's visit (cleaning, consult, pain, etc):
Past Dental Experience: Positive Negative None
If negative, please explain
Has your child had dental x-rays? If yes, when:

Medical Information

Pediatrician Name: Last Visit:
Address: Phone Number:
Is your child being treated for any medical conditions: Yes No
If YES, please explain:
Is your child presently taking any prescribed medications: Yes No
If YES, list medication, dosage and reason:
Has your child ever had an allergic reaction to any medications: Yes No
If YES, list medication(s) & reaction(s) that occurred:
Is your child ever had an allergic reaction to food or other products: Yes No
If YES, list food &/or products (peanuts, latex, etc).
Is your child ever been hospitalized: Yes No
If YES, list year and reason:
Is your child ever had surgery with or without anesthesia: Yes No
If YES, list year and procedure:
Where there any complications from the anesthesia: Yes No
If YES, please explain:
Are your child's immunizations up to date?: Yes No
Does your child have any of the following diseases or conditions? Please check yes or no.
Abuse Yes No Downs Syndrome Yes No Reflux GI Yes No
Anemia Yes No Fainting/Dizziness Yes No Rheumatic Fever Yes No
Asthma Yes No Hearing impairement Yes No Scarlet Fever Yes No
ASD (Autism) Yes No Heart murmur Yes No Scoliosis Yes No
ADD/ADHD Yes No Hepatitis Yes No
Type: 		Seizures Yes No
Birth Defect Yes No Immune Disorders Yes No Sickle Cell Anemia Yes No
Bleeding Disorder Yes No Kidney Disorders Yes No Speech Impairment Yes No
Brain Injury Yes No Leukemia Yes No
Type: 		Spina Bifida Yes No
Cancer Yes No Mental Disorder Yes No Tuberculosis (TB) Yes No
Cerebral Palsey Yes No Nutritional Deficiency\ Yes No Visual Impairment Yes No
Cleft lip/palate Yes No Orthopedic Condition Yes No Syndrome Yes No
Diabetes Yes No Premature Birth Yes No Other Yes No
If your child has a condition/disorder not list above please list here.
If you checked YES to any of the above conditions/disorders list date of diagnosis & any pertinent information.
Check this box if all info listed above is accurate (for parents only).

Parent/Guardian Signature
Date