Pediatric Medical History

Board takeaway

• Interpret. Use the form to start a clinical conversation, then expand positive answers and reconcile medicines, allergies, medical conditions, and prior anesthetic experiences before planning care.
• Document. Identify who supplied the history and who reviewed it.
• Clarify. A checked box, unanswered item, or reported need for premedication requires interpretation.

Medical intake

People, medicines, and prior care

• Record identity, preferred name, birth date, birth sex, gender identity/pronouns, race/ethnicity, and household members.
• Identify physician/specialists, contact details, last visits, and current treatment.
• List prescription/OTC medicines, vitamins, and supplements: name, dose, frequency, start date.
• Describe hospitalizations, surgery, significant injuries/emergency care, anesthetic problems, drug/material allergies, and any reported need for pretreatment medication with its reason.
• Record childhood and HPV immunization status.

Systems and development

• Birth and development: birth/genetic and growth concerns; developmental history; sensory and communication needs.
• Airway and exposure: ear, nose, and throat (ENT), sleep, and airway concerns; smoke or vapor exposure.
• Medical systems: cardiac, pulmonary, hepatic, gastrointestinal/nutritional, renal, musculoskeletal, skin, and endocrine conditions.
• Neurologic and behavioral history: neurologic conditions, seizures, shunts, behavioral/psychiatric concerns, and abuse or neglect.
• Other medical history: blood disorders, bleeding, transfusions, malignancy, transplant, and infections. Add relevant family history.

Dental, prevention, and behavior history

• Capture chief concern, perceived child/family oral health, familial caries, inherited dental traits, sores, halitosis, bleeding, decay, pain, and trauma.
• Ask about grinding/clenching, jaw symptoms, gagging, and sucking beyond age one: type and duration.
• Record brushing/flossing frequency and assistance, brush/toothpaste, water source/filter, and all fluoride exposures.
• Describe meals, restrictions, picky eating, sugar/starch intake, weight concerns, and snack/sweet/gum/beverage frequency and products.
• Document sports/mouthguard use, prior dental visits and reasons, radiograph date, orthodontics, difficult appointments, and expected cooperation.

Updates and signatures

The Recordkeeping best practice recommends reviewing and updating the history at every visit, with a written update at each recall. The form’s questions about events in the past year do not mean history review is only annual.

• Update medical treatment, medicines, past-year health events, anesthesia/allergies, family/home/school disruptions, oral concerns, interval pain/trauma, diet, outside dental care, and other changes.
• Intake/update and infant supplement include guardian signature, relationship, date, and reviewing staff signature; adolescent supplement uses patient/date and staff signatures.

Age-specific supplements

• Infant/toddler: gestational week if premature, birth weight, breast-milk/bottle duration, formula type, bedtime bottle contents, training cup, eruption/teething, brushing/toothpaste start, caregivers, and siblings.
• Adolescent—patient completes: oral pain/appearance, bleaching, dietary changes/supplements, sports/high-speed activities; oral habits, tobacco/vaping, eating disorders, piercings, alcohol/drugs/inhalants, sexual activity, abuse/self-harm, and mood concerns. Ask about possible pregnancy and desired transition to a family/general dentist.
• Sensitive behavior items offer “prefer not to answer”; invite confidential discussion. The form explains potential substance–medication interactions.

Common board traps

Answer aloud

What details accompany a medication?

Record the name, dose, frequency, and start date of every medication.

• Include prescriptions, over-the-counter medicines, vitamins, and supplements.
• Reconcile the list and clarify positive allergy/anesthesia responses before treatment planning.

How do you use the adolescent supplement?

Have the adolescent complete the supplement and review it with them, offering confidential discussion within applicable legal limits.

• Explain that medicines, supplements, substance use, pregnancy, and other sensitive history may affect safe care.
• A “prefer not to answer” response is an invitation to discuss concerns, not a negative finding.
• Record who reviewed the history and clarify answers needed for treatment.

How often should you review and update a child's medical history?

Review and update it at every visit, with a written update at each recall.

• Clarify interval illness/injury, new diagnoses, allergies, and medication changes.
• Identify the history provider and reviewing staff.
• The form’s “past year” questions do not establish an annual-only review schedule.