Pediatric Medical History

As required by law, our office adheres to written policies and procedures to protect the privacy of information about your child that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additonal questions concerning SH ‘O)ie0 WD your child’s health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

PATIENT INFORMATION (CONFIDENTIAL)
Patient Name

Primary Physician’s Name
Address
Specialist physician’s name
Address
PLEASE MARK YES IF YOUR CHILD HAS A HISTORY ANY OF THE FOLLOWING CONDITIONS
DENTAL HISTORY
Does your child have a history of the following?
SUPPLEMENTAL QUESTIONS FOR CHILDREN UNDER 6 YEARS OLD
SUPPLEMENTAL QUESTIONS FOR CHILDREN 6 TO 12 YEARS OLD
SUPPLEMENTAL QUESTIONS FOR ADOLESCENTS (13 TO 17 YEARS OLD)
Both the doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of error or omissions that I may have made inthe completi onof this form.