New Child Health History

Welcome to our practice!

We strive to make each of your child's visits pleasant and comfortable. Please fill out this form completely in ink.

Today's Date

Your Child

Child's Name

Nickname

Sex

Birthdate

Age

Social Security Number

School

Grade

Child's Home Address

City

State

Zip Code

Phone Number

Responsible Party

Name

Relationship

Address

City

State

Zip Code

Phone Number

Email address

Social Security Number

Driver's License Number

Who is responsible for making appointments?

Name

Home Phone

Work Phone

Best Time(s) to Call

Mother

Stepmother

Guardian

Name

Home Phone

Work Phone

Employer

Occupation

Social Security Number

Driver's License Number

Marital Status

Single Married Divorced Widowed Separated

Father

Stepfather

Guardian

Name

Home Phone

Work Phone

Employer

Occupation

Social Security Number

Driver's License Number

Marital Status

Single Married Divorced Widowed Separated

Add secondary insurance

Confidential

Dental and Health History

Your child's overall health as well as any medications which your child takes could have an important interrelationship with the dental care your child receives. Please answer each of the following questions completely.

How often does your child brush?

How often does your child floss?

Is your child's water fluoridated?

Yes No

Does your child take fluoride supplements?

Yes No

Does your child:

Suck Thumb/Finger?

Suck/Bite Lip?

Bite/Chew Nails?

Chew Hard Objects (pencils, etc.)

Clench Jaws?

Previous Dentist

Address

City

State

Zip Code

Date of last dental visit?

Has your child had difficulty with previous dental visits?

Yes No

Child's Physician

Phone Number

Address

City

State

Zip Code

Please explain any medical problems that your child has?

Add additional

Add additional medications

Does your child have a history of allergies/sensitivities/adverse reactions to any drugs or medications (penicillin, Novocain, etc.)?

Yes No

If yes, please describe.

Does your child have a history of allergies to any other substance (latex, environmental, etc.)?

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 be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize the dental staff to perform the necessary dental services my child may need.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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