Child Health / Dental History Form

Patient's Last Name

First Name

Nickname

Date of Birth

Parent's / Guardian's Name

Relationship to Patient

Address

City

State

Zip Code

Home Phone

Work Phone

Have you (the parent/guardian) or the patient had any of the following diseases or problems?

Yes No

Active Tuberculosis
A persistent cough is greater than a three-week duration
Cough that produces blood?

If you answer yes to any of the three items above, please stop and return this form to the receptionist

Please list the name and phone number of the child’s physician:

Name of Physician

Phone

Child's History

1. Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time?

Yes No

If yes, please list

2. Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs?

Yes No

If yes, please explain

3. Is the child allergic to anything else, such as certain foods?

Yes No

If yes, please explain

4. How would you describe the child’s eating habits?

5. Has the child ever had a serious illness?

Yes No

If yes when?

Please describe

6. Has the child ever been hospitalized?

Yes No

7. Does the child have a history of any other illnesses?

Yes No

If yes, please list

8. Has the child ever received a general anesthetic?

Yes No

9. Does the child have any inherited problems?

Yes No

10. Does the child have any speech difficulties?

Yes No

11. Has the child ever had a blood transfusion?

Yes No

12. Is the child physically, mentally, or emotionally impaired?

Yes No

13. Does the child experience excessive bleeding when cut?

Yes No

14. Is the child currently being treated for any illnesses?

Yes No

15. Is this the child’s first visit to a dentist? If not the first visit, what was the date of the last dentist visit?

Yes No

Date

16. Has the child had any problem with dental treatment in the past?

Yes No

17. Has the child ever had dental radiographs (x-rays) exposed?

Yes No

18. Has the child ever suffered any injuries to the mouth, head or teeth?

Yes No

19. Has the child had any problems with the eruption or shedding of teeth?

Yes No

20. Has the child had any orthodontic treatment?

Yes No

21. What type of water does your child drink?

City Water

Well Water

Bottled Water

Filtered Water

22. Does the child take fluoride supplements?

Yes No

23. Is fluoride toothpaste used?

Yes No

24. How many times are the child’s teeth brushed per day?

When are the teeth brushed?

25. Does the child suck his/her thumb, fingers or pacifier?

Yes No

26. At what age did the child stop bottle feeding?

Breast feeding?

27. Does child participate in active recreational activities?

Yes No

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment

I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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

Parent's/Guardian Signature

Date

Signature of Dentist

Your information will be encrypted.