Child Health History Form

Child's Name:

Today's Date:

lt is important to have complete answers. All information is, of course, confidential.

Are you aware of your child having any particular dental problems?

Any discomfort or pain?

ls this your child's first visit to a dental office?

lf not, how long since last examination?

What was done to your child at that time?

Has your child ever had any serious illnesses, such as rheumatic fever, any kind of heart problem or heart murmur, diabetes, etc.?

Yes No

If yes, what?

Is your child sensitive to or allergic to any food or medication?

If so, what?

Who is your child's physician?

Address:

Phone #

Date of your child's last medical check-up:

ls your child under any treatment at present?

lf so, for what?

What medications does your child take?

Is child nursing?

If yes, for how long:

Any issues with nursing?

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

ls the child's dental work covered by any insurance?

lf yes, name of insurance company:

Name of policy holder:

Date of Birth

Social Security Number:

May we ask who recommended you to this office?

Child's name:

Date and year of birth:

Parent's Email

Child's Height

Child's Weight

Home address:

City:

State:

Zip:

Parents Home/Cellphone #:

School:

Grade:

Mother's name:

Occupation:

Where does she work?

Phone:

Ext:

Father's name:

Occupation:

Where does he work?

Phone:

Ext:

Responsible person:

What professional referred you to our office?

Name of Professional:

Type of Professional:

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.

Date:

Parent Name/Signature:

Your information will be encrypted.