Pediatric Medical History Form

Pediatric Medical History

Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Child's Full Name:

Nickname:

Primary Physician:

Gender: M F

Tel:

Cell:

Parent SS#:

Date of Birth:

Height:

Weight:

Date of Last Physical:

Medical Specialists:

Is your child up to date on immunizations against childhood disease? ............................................................... Y N

Is your child taking any medications, vitamins, or dietary supplements? ........................................................... Y N

List name, dose, how often, start date

Has you child ever had a serious injury/surgery or been hospitalized/ER? ......................................................... Y N

List date and describe

Has your child ever had a reaction to or problem with an anesthetic? ................................................................. Y N

Has your child ever had a reaction or allergy to an antibiotic or other medication? ............................................. Y N

Is your child allergic to Latex, foods, dyes, or anything else? ............................................................................. Y N

Please mark Y for "yes" if an item below pertains to your child or mark N for "no" if the item does not apply to your child.

Y N

Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions

Y N

Problems with physical growth or development, weight, or history of eating disorder

Y N

Sinusitis, chronic adenoid/tonsil infections

Y N

Sleep apnea/snoring, mouth breathing, or excessive gagging

Y N

Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease

Y N

Irregular heart beat or high blood pressure

Y N

Asthma, reactive airway disease, wheezing, or breathing problems

Y N

Frequent colds or coughs, or pneumonia

Y N

Frequent exposure to tobacco smoke

Y N

Jaundice, hepatitis, or liver problems

Y N

Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems

Y N

Bladder or kidney problems

Y N

Arthritis, scoliosis, limited use of arms or legs, or muscle/ joint/ bone problems

Y N

Rash/hives, eczema, or skin problems

Y N

Impaired vision, hearing, or speech

Y N

Developmental disorders, learning problems/delays, or intellectual disability

Y N

Cerebral Palsy, brain injury, epilepsy, or seizures

Y N

Autism/autism spectrum disorder

Y N

Recurrent or frequent headaches/migraines, fainting, or dizziness

Y N

Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous)

Y N

Attention deficit/hyperactivity disorder (ADD/ADHD)

Y N

Behavioral, emotional, communication, or psychiatric problems/treatment

Y N

History of known abuse (physical, psychological, emotional, or sexual) or neglect

Y N

Diabetes, hyperglycemia, or hypoglycemia

Y N

Precocious puberty or hormonal problems

Y N

Thyroid or pituitary problems

Y N

Anemia, sickle cell disease/trait, or blood disorder

Y N

Hemophilia, bruising easily, or excessive bleeding

Y N

Transfusions or receiving blood products

Y N

Cancer, tumor, chemotherapy, radiation therapy, or bone marrow or organ transplant

Y N

Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus, methicillin resistant staphylococcus aureaus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS

Provide details for any "Yes" responses above:

Is there any other medical history pertaining to this child or his/her family:

What is your primary concern about your child's oral health?

Your child's oral health is... Excellent Good Fair Poor

Do any of the following apply to your child? For each "yes" please describe

Family history of cavities (who) ................... Y N

Inherited dental characteristics....................... Y N

Mouth sores or fever blisters......................... Y N

Bad breath...................................................... Y N

Cavities/decayed teeth.................................... Y N

Toothache...................................................... Y N

Injury to teeth, mouth, or jaws....................... Y N

Clenching/grinding........................................ Y N

Jaw/Joint problems (popping etc.)................ Y N

Excessive gagging......................................... Y N

Sucking habit after 1 year of age................... Y N

Pacifier Thumb Finger Other

What age did they stop?

How often does your child brush their teeth?

How often does your child have the following?

Does someone help them? Y N

Candy or other sweets

Rarely 1-2/day 3 or more/day

How often does your child floss their teeth?

Products:

Does someone help them? Y N

Chewing Gum

Rarely 1-2/day 3 or more/day

What toothpaste does your child use?

Type:

Snacks between meals

Rarely 1-2/day 3 or more/day

Source of drinking water at home? City/Community Private Well

Usual Snack:

Do you use a water filter? Y N

Type:

Soft Drinks*

Rarely 1-2/day 3 or more/day

Does your child receive any fluoride sources?

(*juice, fruit flavored drinks, sodas, sweetened beverages, sports drinks, or energy drinks)

Over the couter rinse School fluoride program

Pediatrician applied fluoride Prescription fluoride toothpaste

Any other significant dietary habits?

Prescripiton drops/tablets/vitamins

Is your child on a special or restricted diet? Y N

Has your child been examined or treated by another dentist? Y N

Describe:

Date of last visit?:

Were x-rays taken?

Does your child have a diet high in sugars or carbohydrates? Y N

Date of last x-rays?:

Do you have any concerns regarding your child’s weight? Y N

Has your child ever been evaluated by an orthodontist? Y N

Describe:

When?:

Any orthodontic treatment done?

Does your child participate in any sports or similar activities? Y N

Has your child ever had a difficult dental appointment Y N

Does your child wear a mouthguard during these activities? Y N

Describe:

Is there anything else we should know before treating your child?

The information on both pages of this form is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form is solely my responsibility.

Signature of parent/guardian

Relationship to Patient

Date