Pediatric Medical History PEDIATRIC DENTAL HISTORY Did birth mother have any health problems during pregnancy? yes no Has your child needed frequent use of liquid medication? yes no Are all of your child's immunizations up to date? yes no Has your child been diagnosed with any illness? yes no Please list any medications your child is taking and reason: Please list any surgeries your child has had, reason and dates: Is your child allergic to any medications? yes no If yes, please list: Does your child suffer from any other allergies? yes no If yes, please list: DIET AND NUTRITION Is/was your child breastfed? yes no Is your child on a special diet? yes no Describe: Does your child have difficulty swallowing? yes no How many times does your child eat a snack each day: 0 1 2 3 4 5+ FLUORIDE ADEQUACY Do you have well water? yes no If yes, has the water been tested for fluoride content? yes no Test results: ORAL HABITS Does your child have any oral habits? yes no Explain: ORAL DEVELOPMENT Do your child's teeth seem crooked or misaligned? yes no ORAL HYGIENE How often does your child brush his/her teeth? 0 1 2 3 4+ Does your child use a manual or electric toothbrush? manual electric BEHAVIOR Is this your child's first visit to the dentist? yes no How do you think your child will act towards the dentist? Describe: SLEEP BEHAVIOR Does your child have difficulty sleeping? yes no Does your child experience nightmares? yes no What position does your child normally sleep in? On Back On Stomach Left Side Right Side Varies Does your child have trouble breathing or struggles to breathe? yes no Does your child have a tendency to sleep with their mouth open? yes no Do you notice if your child snores or makes other noises? yes no Does your child breathe through their mouth during the day? yes no DEVELOPMENT Has your child been growing at a normal rate since birth? yes no Is your child overweight? yes no Does your child have frequent colds? yes no Does your child have allergies? yes no Has your child been diagnosed with ADD/ADHD? yes no PLEASE INDICATE YOUR RELATIONSHIP TO THIS CHILD Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.