Child Health/Dental History Form
Child’s Name:___________________Middle__________________ Last________________________
Nickname:_____________________ Date Of Birth:_________________ Gender:________________
Address_____________________________________ State______________ Zip_________________
First Parent info. Please circle one: MOTHER FATHER LEGAL GUARDIAN
Name:______________________________________ Phone____________________
Can we email you for appointment confirmation? YES NO
Second Parent info. Please circle one: MOTHER FATHER LEGAL GUARDIAN
Name:_____________________________________ Phone_____________________
Can we email you for appointment confirmation? YES NO
How did you hear about our office?_____________________________________________________
If your child is currently sick has a productive cough or a positive strep test, please3 see
receptionist before completing this form.
Please list the name/number of your child’s pediatrician as we3ll as any frequently seen
specialist, if applicable:
Name of pediatrician:__________________________________phone_________________________
Name of specialist:____________________________________phone__________________________
Dental Insurance Information:
Policy Owner Name:_________________________________Employer________________________
Insurance company name:_____________________________ Group#_________________________
ID #_______________________________ SSN______________________ DOB___________________
Relationship to child. Please circle one: FATHER MOTHER LEGAL GUARDIAN
OTHER____________________
Please review carefully and check if your child has any history of, or condition related to, any of
the following:
o
o
o
o
o
o
o
ANEMIA
ARTHRITIS
ASTHMA
AUTISM
BLADDER/KIDNEY
BLEEDING disorder
BONE disorder
CANCER
CEREBRAL PALSY
CHICKEN POX
CHRONIC SINUSITIS
DIABETES
EAR ACHES/INFECTIONS
ENLARGED TONSILS
EPILEPSY/SEIZURES
FAINTING
GROWTH PROBLEMS
HEADACHES
HIV/AIDS
HYPERACTIVITY
ADHD/ADD
o LIVER/HEPATITIS
SICKLE CELL
TUBERCULOSIS
o MEASELS
SNORING
STD
o MONONUCLEOSIS
SPEECH/HEARING
VISION disorders
o MUMPS
SKIN
OTHER______________
o PREGNANCY (teens)
THYROID
_____________________
Health and Dental History
1. Is your child taking any medications (prescription, over-the-counter, vitamin
supplements)? YES NO
If yes, please list all_____________________________________________________________
2. Is your child allergic to (please explain if yes to any):
a. Any medications?___________________________________________________________
b. Any foods?_________________________________________________________________
c. Any metals?________________________________________________________________
d. Seasonal or other?___________________________________________________________
3. Has your child ever been hospitalizes or had any type of surgery? YES NO
If yes, please explain____________________________________________________________
4. Is your child allergic to LATEX? YES NO
5. Has your child ever received sedation or general anesthesia? YES NO
If yes, has your child ever had any complications with sedation or general anesthesia?
Please explain_________________________________________________________________
6. Does your child have any mental, developmental, or physical impairment?
Please explain_________________________________________________________________
7. Has your child ever experience excessive bleeding when cut or injured? YES NO
8. Does your child have any genetic or inherited disorders? YES NO
If yes, please explain___________________________________________________________
9. Is your child being treated for any illness not yet discussed on this form?
10. Are your child’s immunizations up to date? If not, please explain?______________
11. Is this the child’s first dental visit? If not, date of last visit?___________________________
12. Has your child ever had an unfavorable experience or visit to a dental office? Please
explain________________________________________________________________________
13. Have there been any injuries to your child’s mouth, teeth, or head? Please
explain________________________________________________________________________
14. What type of water does your child drink?________________________________________
15. Does your child take fluoride supplements? YES
16. Is fluoride toothpaste used?
YES
NO
NO
17. How often are your child’s teeth brushed per day?_______ What time of day?__________
18. Is the brushing supervised and/or assisted?___________________________
19. Does your child participate in any sports or any other active recreational activities?_____
20. Has your child complained of any recent dental pain?
21.
22.
23.
24.
25.
26.
27.
Please explain:_________________________________________________________________
Any other dental concerns/comments not yet discussed on this
form?_________________________________________________________________________
Is your child breast feed or was the child ever breast feed? YES NO
At what age was it stoped?__________________________
Is the child taking a bottle? YES NO Contents?____________aged stopped________
Sippy cup used? YES NO Contents?_________________ aged stopped__________
THUMB/FINGER SUCKING? YES NO
Aged stopped?______________
Pacifier use? YES NO Aged stopped?______________
TEETH GRINDING? YES NO Aged stopped?__________________
As this child’s parent or legal guardian, I acknowledge that the completed information in
this form is correct to the best of my knowledge. I understand that misrepresentation or
withholding medical/dental information can be harmful to my child during treatment.
Parent Signature__________________________________Print Name_______________________
Today’s Date________________________________