Updated Medical History - Fishman Pediatric Dentistry

Fishman Pediatric Dentistry / 552 Jacksonville Dr. / Jacksonville Beach Fl, 32250

Child's Name*

First Last

DOB*

Is your child under the care of another physician/specialist?

Yes
No

Name of other physician/specialist:

Reason for seeing other physician/specialist:

Is your child receiving any medication?*

Yes
No

List medication(s):

Is your child allergic to LATEX?*

Yes
No

Other allergies:*

Has your child been hospitalized, surgeries or illness?*

Yes
No

Hospitalization details:

Has your child had a history of any of the following?

Heart Trouble, heart murmur, or heart surgery*

Yes
No

Rheumatic fever or scarlet fever*

Yes
No

Asthma, TB, or lung/breathing problems*

Yes
No

HIV or AIDS*

Yes
No

Hemophilia, Sickle Cell anemia, or any other blood disorders/problems*

Yes
No

Hepatitis or liver problems*

Yes
No

Kidney infections*

Yes
No

Diabetes*

Yes
No

Congenital birth defects*

Yes
No

Cleft lip or palate*

Yes
No

Cancer, tumor or leukemia*

Yes
No

Epilepsy/seizures*

Yes
No

Autism Delay/Cerebral palsy*

Yes
No

Thyroid or glandular problems*

Yes
No

Please list any history that may not be on the list above:

DENTAL HISTORY

Has your child received dental care at another facility since your last visit at Fishman Pediatric Dentistry?*

Yes
No

If yes, when and where was your child's last dental visit?

Did your child have x-rays done?

Yes
No

Was any treatment recommended?

Yes
No

Treatment recommended:

Have there been any injuries to your child's teeth in the past (chips, fractures, etc)?

Yes
No

List injuries:

Were there any teeth extracted/missing?

Yes
No

List extracted/missing teeth details:

Does your child have any other siblings seen by us?

Yes
No

List sibling(s):

Is there any additional information we should know to ensure a positive experience at our office?

CONSENT

I understand that the information I have given is correct and to the best of my knowledge, and that it will be held in the strictest of confidence. Because my child is a minor, it is necessary that signed permission be obtained from a parent or legal guardian before any dental services can be rendered. I give my consent to Dr. Fishman and his staff to perform such treatment, services, medication, local anesthesia and/or analgesia necessary to treat any dental/oral abnormality and/or infections.

Parent/Guardian Signature

Date*

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