Myers Pediatric Dentistry & Orthodontics -
Childrens Medical History
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3200 Old Jennings Rd.
Middleburg FL 32068
(904) 505-2010
3267 Hodges Blvd. #13
Jacksonville FL 32224
(904) 361-3370
Patient Name
Chart #
Select Location
Myers Pediatric Dentistry & Orthodontics | 3200 Old Jennings Rd., Middleburg, FL
Myers Pediatric Dentistry & Orthodontics | 3267 Hodges Blvd. #13, Jacksonville, FL
Patient Dental History
Please answer the following questions
Does your child brush, floss, or use any other dental aids?
Yes
No
Is your child taking fluoride of any form?
Yes
No
Do your child’s gums bleed while brushing or flossing?
Yes
No
Does your child feel pain to any teeth?
Yes
No
Do you have any areas of concern?
Yes
No
Has your child had any injuries to his or her mouth, teeth, or head?
Yes
No
Has your child ever experienced clicking or pain of the jaw?
Yes
No
Has your child ever experienced difficulty opening, closing, or chewing?
Yes
No
Does your child breathe through his or her mouth?
Yes
No
Does your child have frequent headaches?
Yes
No
Does your child clench or grind his or her teeth?
Yes
No
Do you assist your child while flossing and brushing?
Yes
No
Are you pleased with the appearance of your child’s smile?
Yes
No
Has the mother or primary caregiver had cavities in the past 12 months?
Yes
No
Does your child sleep with a bottle at night?
Yes
No
Does your child’s bottle or sippy cup contain fluid other than milk or water?
Yes
No
Does your child suck his or her thumb and/or fingers?
Yes
No
Does your child bite his or her nails?
Yes
No
Does your child enjoy chewing gum?
Yes
No
Does your child drink sodas?
Yes
No
Patient Medical History
Physician
Office Phone
Routine Exams?
Yes
No
1. Is your child under medical treatment now?
Yes
No
2. Has your child been hospitalized for any surgical operation or serious illness?
Yes
No
3. Does your child have or has your child had any of the following?
Fainting/Seizures
Yes
No
Low Blood Pressure
Yes
No
High Blood Pressure
Yes
No
Epilepsy
Yes
No
Convulsions
Yes
No
Abnormal Bleeding
Yes
No
Hemophilia
Yes
No
Anemia
Yes
No
Kidney or Liver Disease
Yes
No
Congenital Heart Defect
Yes
No
Heart Murmur
Yes
No
Heart Trouble
Yes
No
Respiratory Problems
Yes
No
Thyroid Problem
Yes
No
Leukemia
Yes
No
Cancer
Yes
No
Radiation Therapy
Yes
No
Tuberculosis
Yes
No
Hearing Impairment
Yes
No
Diabetes
Yes
No
AIDS or HIV
Yes
No
Jaundice
Yes
No
Hepatitis
Yes
No
Stomach Ulcers
Yes
No
Hay Fever
Yes
No
Allergies
Yes
No
Asthma
Yes
No
ADHD
Yes
No
Special Needs
Yes
No
Other
Yes
No
4. Is your child taking any medications (including non-prescription medicines)?
Yes
No
5. If yes, what medications is he or she taking?
6. If your child has asthma, when was his or her last episode?
7. Is your child allergic to any of the following: (Please check which ones)
Local anesthetics
Aspirin
Latex
Iodine
Sulfa Drugs
Red Dye
Penicillin or other antibiotics
None
Other
If other, please specify
Authorization, Release, & Agreement to Pay for Services Rendered
I authorize the dentist to release any information including the diagnosis and the records of any treatrment or examination rendered to me to third party payers and/or health practitioners.
I authorize and hereby request my Insurance company to pay directly to the dentist (or the dental practice) insurance benefits that otherwise are payable to me.
I understand that my dental insurance carrier may pay less than the actual bill for services.
I agree to be responsible for all services rendered on my behalf or on behalf of my dependents.
I certify that I have read and understand the above information. To the best of my knowledge, the above answers have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health.
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