Child's Dental & Medical Health History Information

To the parents / guardians of the patient: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat the patient.

PATIENT INFORMATION

Last Name

First Name

Middle Name

Date of Birth

Nickname

Parent's Guardian's Name

Relationship to Patient

Email address

Home Phone

Cell Phone

Work Phone

Mailing Address

City

State

Zip

Have you (the adult) or the patient (the child) had?

A cough that's lasted longer than three weeks

Active Tuberculosis

A cough that produces blood

PATIENT'S DENTAL HEALTH HISTORY

What is the reason for your visit today?

How would you describe the patient's oral health?

Excellent Good Fair Poor

If yes, where?

If no, when was the patient's last dental exam?

What was done at that appointment?

When was the last time the patient had dental x-rays taken?

If yes, please describe what happen?

How often are the patient's teeth brushed? (Times)

Per (day/week)

At what time(s) of day are the teeth brushed?

If yes, please describe what happened and when it happened?

If yes, please describe those activities here

At what age did the patient stop breastfeeding?

At what age did the patient stop bottle feeding?

Has the patient ever experienced any sleep-related breathing disorders?

Mouth breathing

Snoring

Trouble breathing during sleep

PATIENT'S MEDICAL HEALTH HISTORY & VACCINATION STATUS

Please list the name and phone number of the patient's physician

Doctor's Name

Phone No.

If yes, please explain

If yes, what is the illness and when did it start?

If yes, what was the illness and when did it happen?

When and why?

Add new row

If yes, please explain

How would you describe the patient's eating habits?

If other, please specify

MEDICATIONS & ALLERGIES

If yes, please list them here

If yes, please list those medications and what happened when patient took them

If yes, please describe the allergy and the reaction

NOTE: I understand that it's important for both the dentist and the patient or his/her parent/guardian to talk honestly about the patient's health before dental treatment starts. I have answered all of the questions above completely and accurately. I understand that the dentist and his/her staff need this information so the patient receives the right kind of dental care. I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

The dentist and I have talked about any questions I had about this form.
I will not hold the dentist, or any other member of his/her staff, responsible for anything they did, or didn't do, because of any mistakes I might have made in filling out 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.

Signature of Parent/Legal Guardian

Date

FOR COMPLETION BY DENTIST

Comments

Office Use Only

Medical Alert

Premedication

Allergies

Anesthesia

Reviewed By

Date

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