LOMA LINDA UNIVERSITY CENTER FOR DENTISTRY AND ORTHODONTICS
PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE
Name:______Date:______
1. Why have you brought your child to the dentist? ______
______
2. Has your child had a previous visit to a dentist?...... Yes No
3. Has your child ever had any of the following?
Tooth Abscess (gum boil) …………………………………………………………. ….. Yes No
Swelling or lumps in the mouth? ……………… …………………………………….. Yes No Clicking, popping or pain in the jaws? …………………………………………...……. Yes No
Traumatic injuries to the teeth, jaw, head or neck?...... Yes No
4. Does your child have any oral habits?...... Yes No
If yes, please explain:
______
5. Is your child presently nursing or drinking from a bottle? …………………………………….. Yes No
6. Are your child’s teeth brushed and flossed? ……….. …………………………………………. Yes No
7. By what sources does your child receive fluoride? ______
8. Are your child’s immunizations up to date?...... Yes No
9. Does your child have any health problems?...... Yes No
If yes, please explain:
______
10. Has your child seen a physician in the past 12 months?...... Yes No
11. Is your child under the care of a physician at this? …………………….……………………….. Yes No
12. Has your child had any physical or mental problems since birth?……………………………… Yes No
13. Is your child taking any medications? …………………………………….……………………. Yes No
14. Has your child ever been hospitalized or in the emergency room?...... Yes No
15. Were difficulties encountered during the pregnancy of this child?...... Yes No
16. Does your child have any history of allergic reactions? ………………….……………………... Yes No
17. Does your child have any limitations in sports activities?...... Yes No
18. Does your child get motion sickness?...... Yes No
19. Does your child have any problems with learning/concentration or speech? ……….…………… Yes No
20. Does your child have or has had any Heart or Blood Vessel problems? ……..…………………. Yes No
21. Does your child have or has had any lung or breathing problems? ……………………………… Yes No
22. Does your child have or has had any blood or immune system problems?……………………… Yes No
23. Does your child have any eye or ear problems? ……….……………………………………….. Yes No
24. Does your child have any Genetic, Neurological or Developmental disorders? ………………… Yes No
25. Does your child have or had any bone or muscle problems? …………………………………… Yes No
26. Does your child have or has had any Gastro Intestinal, Genitourinary or Endocrine problems? Yes No
27. Does your child have or has had any cancers/tumors? ….……………………………………….. Yes No
28. Does your child have a history of drug or alcohol abuse?.………………………………………. Yes No
29. Does your child have a history of physical or sexual abuse?...... Yes No
30. Is this child adopted?...... Yes No
Questions for Adolescent Girls:
31. Do you have any menstruation problems? ……………………………………………………… Yes No
32. Is there any chance you are pregnant?...... Yes No
33. Are you taking birth control pills? ……………………………………………………………… Yes No
34. Does your child have any other medical or dental problems not mentioned here or any additional information that may affect your child’s treatment?...... ……………... Yes No
If yes, please explain:
______
My signature below indicates that I understand and have answered all of the above questions to the best of my knowledge. I request and freely consent for my child to have a complete clinical examination and to the performance of any additional tests or procedures, which are deemed necessary after the examination in order to determine my child’s dental treatment needs. I have been informed that these procedures will be discussed with me prior to them being done.
______
Date Patient, Parent or Guardian Signature