TobaccoDrug UseTuberculosisVenereal DiseasePatients NameParentsGuardians NamePatients Sex Is the child taking any medications at this time If yes please list How would ID: 899258
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1 Child Health/Dental History Form Tobacco
Child Health/Dental History Form Tobacco/Drug UseTuberculosisVenereal Disease PatientÃs NameParentÃs/GuardianÃs NamePatientÃs Sex Is the child taking any medications at this time? If yes, please list: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ How would you describe the childÃs eating habits? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes 1.Active Tuberculosis, 2. Persistent cough greater than a three-week duration, 3.Cough that produces blood?Has the child ever been hospitalized? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Does the child have a history of any other illnesses? If yes, please list: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Has the child ever received a general anesthetic? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does the child have any inherited problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Does the child have any speech difficulties? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Has the child ever had a blood transfusion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Is the child physically, mentally, or emotionally impaired? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Does the child experience excessive bleeding when cut? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is the child currently being treated for any illnesses? . . . . . . . . . . . . . . . . . . . . . . . . .
2 . . . . . . . . . . .Is this the childÃ
. . . . . . . . . . .Is this the childÃs first visit to a dentist? If not the first visit, what was the date of the last dentist visit? Date:Has the child had any problem with dental treatment in the past? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Has the child ever had dental radiographs (x-rays) exposed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Has the child ever suffered any injuries to the mouth, head or teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Has the child had any problems with the eruption or shedding of teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Has the child had any orthodontic treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Well water Does the child take fluoride supplements? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Is fluoride toothpaste used? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .How many times are the childÃs teeth brushed per day? _____ When are the teeth brushed? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Does the child suck his/her thumb, fingers or pacifier? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .At what age did the child stop bottle feeding? Age _________ Breast feeding? Age _________ P.O. BOX OR MAILING ADDRESSSTATE LASTFIRSTINITIAL Please list the name and phone number of the childÃs physician: CHILDÃS HISTORY11. I certify that I have read and understan
3 d the above. I acknowledge that my quest
d the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to mysatisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not o oo oo oo oo oo oo oo oo o11.o oo oo oo oo oo oo oo oo oo oo oo oo o Yes No Comments on parent/guardian and patient interview concerning health history _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Significant findings from questionnaire or oral interview _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dental management considerations _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Mediical Alert Anesthesia Reviewed by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Date_______________ ParentÃs/GuardianÃs Signature Signature of DentistDate American Dental Association, 2002To Reorder call 1-800-947-4746or go online at www.adacatalog.org Ben Thompson10251 Little Brier Creek Ln, Ste. 1019194842617Susan ThompsonRaleigh, NC Hipaa Authorization for a Minor I am the custodial parent having legal custody of _____________________, a minor child. I.T P I consent to receiving emails and/or text messages on behalf of my child.Emails and texts are primarily used mail address: _____________________________________________________________Phone # for text: __________ ______________________________________________ _________________________ Signature of Custodial ParentDate