Basking Ridge Pediatric Dentistry
Medical History Update
Date*
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/
Child's Name*
DOB*
/
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Cell Phone Number
Pediatrician
Home Phone Number
Email Address
Address
City
State
Zip Code
Have there been any changes in your child’s health?*
Choose One
No
Yes
If yes, please explain.
Does your child take Fluoride supplements?*
Choose One
No
Yes
I don't know
If yes, please indicate which dosage:
Choose One
0.25 mg
0.50 mg
1.0 mg
I don't know
Does your child have any drug allergies?*
Choose One
No
Yes
If yes, please list any drug allergies.
Please list any medications your child is taking.
Has your child ever had heart murmur, heart valve problems ?
No
Yes
If yes, please explain.
Has your child had any history of diabetes, bleeding, kidney or liver disease?
No
Yes
If yes, please explain.
Do you have any dental concerns about your child?
Signature*
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Relationship to Patient*
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