Medical & Dental History

Child's Biographical, Medical, and Dental History

Please type all information. Please include area code with all phone numbers.

Last Name

First Name

Middle Name

Sex

Age

Date of Birth

Race

Grade

School

Address

City

State

Zip Code

Father's Name

Father's Home Phone

Father's Cell Phone

Mother's Name

Mother's Home Phone

Mother's Cell Phone

Do both parents live together?

Yes No

If not, with whom does the child live?

Father's occupations/employer:

Work Phone

Mother's occupations/employer:

Work Phone

Email address

Relative

Phone

Child's Physician

Phone Number

Address

City

State

Zip Code

Does your child have any other medical condition?

Yes No

Is your child taking any medicine?

Yes No

Is your child allergic to any medicine or food?

Yes No

Has your child ever been hospitalized?

Yes No

Is this your child's first visit to the dentist?

Yes No

Were there any problems with previous dental treatment?

Yes No

Is your child using fluoride tablets, drops, or rinses?

Yes No

Has your child had a toothache recently?

Yes No

Does your child suck a thumb, finger, or have any other oral habit?

Yes No

Has your child ever injured his/her teeth or jaws?

Yes No

Does your child have a dental condition about which you are especially concerned?

Yes No

What is the source of your child's drinking water?

Public Water Well Water

How often are your child's teeth brushed?

By whom?

I acknowledge that this information is correct and hereby authorizes a dental examination for my child including necessary radiographs, photographs, and acceptable methods to accomplish these services. I authorize the use of any radiographs, photographs, and records for the purpose of teaching, research, and scientific publication.

Disclaimer: 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.

Parent or Guardian's Signature

Date

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