Portsmouth Pediatric Dentistry

Today's Date

Child's First, Middle Initial, & Last Name: Date of Birth:
Any dental concerns for today?
Approximate weight of your child? (in LBS)
Is a physician treating your child presently for a specific illness?
Y: N:
Is your child taking any medications at this time?
Drug               Dose               Frequency               Reason




Y: N:
Has your child taken any unusual medications in the past and if so please explain?
Y: N:
Has your child had any allergic or unusual reactions to medications or food?
Y: N:
Has your child ever been hospitalized or had any operations? If so, when and for what reason.
Y: N:
Is your child up to date on all of his/her immunizations? Y: N:
May we take x-rays today (if they are due)? Y: N:
Does your child have any history of any of the following conditions? Check if yes.
ADD or PDD
AIDS or HIV
Anemia
Asthma
Autism
Bleeding Disorders
Cerebral Palsy
Cystic Fibrosis
Diabetes
Down Syndrome
Emotional Problems
Hearing Problems
Heart Murmur/Defect
Kidney Disease
Latex Allergy
Learning Problems
Sensory Issues
Liver Disease
Rheumatic Fever
Seizures
Sickle Cell Dis.
Speech Problems
Tuberculosis
Vision Problems
Sensory Problems
Signature:

Relationship to Patient:

Do we have your permission to contact you through email/text to confirm appointments? Y: N:

ADOLESCENT SECTION (13 and older)


Although dental personnel treat the area in and around the mouth, the mouth is part of your entire body. Health conditions or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Is your child taking oral contraception? Y: N:
Is your child pregnant? Y: N:
Does your child use tobacco? Y: N:
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to the Portsmouth Pediatric Dentistry Privacy Policy.