Medical & Dental History

Take fluoride supplements Use a pacifier Suck thumb or finger Bite or chew nails Grind teeth Clench jaws

Asthma Autism Anemia ADHD Bleeding Problems Brain Injury Cancer Cerebral Palsy Convulsions/Seizures Cystic Fibrosis Developmentally Delayed Diabetes Eye Problems Hearing Loss Heart Murmur Hepatitis HIV/AIDS Jaundice Kidney Problems Leukemia Measles Mental Disability Orthopedic Problems Otitis Pneumonia Rheumatic Fever Scarlet Fever

Authorization and Release: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk. I authorize the dental staff to perform the necessary dental services and to release information to third-party payers as necessary.