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Child`s Name _______________________________
Dr. Jason Bongiovi
Patient Medical History
Is your child currently under the care of a physician/pediatrician?*
Yes
No
If yes, what is the name of the doctor/practice?*
Is your child taking any medication?*
Yes
No
If yes, please list them:
Is your child allergic to any medicines or food?*
Yes
No
If yes please list
Is your child allergic to latex or itching or swelling with dental visits?*
Yes
No
Has your child ever had any surgery (including ear tubes, tonsils and adenoids, etc)?*
Yes
No
If yes, please list surgeries:
Has, your child ever been hospitalized?*
Yes
No
Please list the reasons and the names of hospitals:
Please check any of these conditions which your child presently has or has previously had:
Anemia
Ear Disorders
Hyperactivity
Premature Birth
Asthma
Seizure Disorders
Cerebral Palsy
Rheumatic Fever
Bleeding Problems
Eye Disorders
Kidney Disease
Stomach Problem
Bone Disorder
Autism
Liver Disease
Skin Disease
Brain Disorder
Heart Condition
Lung Disease
Speech Problem
Shunt
Heart Murmur
Developmental Delay
HIV Positive
Cancer
High Blood Pressure
Muscle Disorder
Other Medical Condition
Diabetes
Hormone Disorder
Downs Syndrome
MTHFR Mutation
None - to the best of my knowledge, my child is healthy and has not had any of these conditions
Is this your child`s first visit to the dentist?*
Yes
No
Please list dates and services performed
What is your main concern about your child?*
What is the source of your drinking water?*
City/County System
Well
Bottled
Has your child ever been given fluoride tablets, drops, or rinse?*
Yes
No
Has your child ever had any injuries to the mouth or face area?*
Yes
No
Does your child have any of the following habits: finger/thumb sucking, pacifier?*
Yes
No
How often are your child`s teeth brushed?*
By whom?*
Additional Comments:
I certify that the above information is accurate and complete to the best of my knowledge. i understand that any errors or omissions could harm my child`s dental treatment and/or their overall health. I will not hold Dr. Jason Bongiovi or his staff responsible for the result of any errors or omissions in the information l have provided on this form.
Legal Guardian/Patients Signature:*
Date*
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