Health History Questionnaire In order to best serve your child, please fill out the below health history questionnaire. It is required to diagnose and fulfill prescriptions if needed. Please enable JavaScript in your browser to complete this form. - Step 1 of 5Patient Name *Date of Birth *SexMaleFemaleWeightName/Address/Phone Number of primary physicianName/Address/Phone Number of medical specialists:Is your child being treated by a physician at this time? Reason?Where do you live? *OhioPennsylvaniaWest VirginiaOtherNextIs your child taking any medication (prescription or over the counter), vitamins, or supplements? Dose and frequency, date started:Has your child ever been hospitalized, had surgery or a significant injury, or been treated in an emergency department? List date & describeHas your child ever had a reaction to or problem with an anesthetic? *YesNoExplain reaction or problem with anesthetic *Has your child ever had a reaction or allergy to an antibiotic, sedative, or other medication? *YesNoExplain your childs reaction or allergy to an antibiotic, sedative, or other medicationIs your child allergic to tree nuts, soy, Birch trees, etc? List *NextPlease mark select from the below list if your child has a history of the following conditions. For each YES, provide details in the box at the bottom of this list. *Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditionsProblems with physical growth or developmentSinusitis/chronic adenoid/tonsil infectionsLarge tonsils, sleep apnea/snoring, mouth breathing, or excessive gaggingCongenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart diseaseIrregular heart beat or high blood pressureRSV, Asthma, reactive airway disease, wheezing, or breathing problemsFrequent colds or coughs, or pneumoniaIs there anyone in the child’s life that smokes?Jaundice, hepatitis, or liver problemsGastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problemsLactose intolerance, food allergies, nutritional deficiencies, or dietary restrictionsProlonged diarrhea, unintentional weight loss, concerns with weight, or eating disorderBladder or kidney problemsArthritis, scoliosis, limited use of arms or legs, muscle/bone/joint problemsRash/hives, eczema, or skin problemsImpaired vision, visual processing, hearing or speechDevelopmental disorders, learning problems/delays, or intellectual disabilityCerebral palsy, brain injury, epilepsy, or convulsions/seizuresAutism/Autism spectrum disorderRecurrent or frequent headaches/migraines, fainting, or dizzinessHydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous)Attention deficit/hyperactivity disorder (ADD/ADHD)Behavioral, emotional, communication, or psychiatric problems/treatmentAbuse (physical, psychological, emotional, or sexual) or neglectDiabetes, hyperglycemia, or hypoglycemiaPrecocious puberty or hormonal problemsAnemia, sick cell disease/trait, or blood disorderHemophelia, bruising easily, or excessive bleedingTransfusions or receiving blood productsCancer, tumor, or other malignancy; chemotherapy, radiation therapy, or bone marrow or organ transplantMononucleosis, tuberculosis, scarlet fever, cytomegalovirus, methicicillin resistant staphylococcus aureus (MRSA), sexually transmitted disease, or human immunodeficiency virus (HIV)/AIDSNone of theseWhat is your primary concern about your child’s oral health?How would you describe your child’s oral health? ExcellentGoodFairPoorDoes your child have a history of any of the following? If yes select and describe below. *Inherited dental characteristics Mouth sores/ fever blisters Bad breath Cavities/decayed teeth Toothache Injury to teeth, mouth or jaws Clinching/grinding/his/her teeth Jaw joint problems (popping etc) Excessive gagging Sucking habit after one year of Describe Above SelectionNextHow often does your child brush his/her teeth? Please check all sources of fluoride:Drinking WaterToothpastePrescriptionRinseFlouride from schoolFlouride from dental officeHas your child been examined or treated by another dentist? *YesNoConsent For Consult - I accept the onlinekidsdentis.com terms and conditions for consult (terms located on website footer) *YesNoSignature of parent or guardian ( please type name) *Date / Time *DateTimeNextPediatric Dental Consult *Price: $ 79.99Total$ 0.00Email *Stripe Credit Card *CardName on CardPhoneSubmit
