Child Health History Form (Under Age 16)

Child Health History Form
Patient's Name:*

First NameLast Name
Nickname:
Date of Birth:*

MonthDayYear
Date
Sex:*

MaleFemale
1st Parent/Legal Guardian Name:*
Relationship to Patient:*
Phone Number*
2nd Parent/Legal Guardian Name:
Relationship to Patient:
Phone Number
Medical History
Name of Primary Care Physician:*
Phone Number:*
Date of Last Primary Care Visit:*
Has the patient had any history of, or conditions related to, any of the following?

AnemiaArthritisAsthmaBleeding DisorderBone/Joint ProblemsCancerCerebral PalsyChicken PoxChronic SinusitisDiabetesEar Aches/InfectionsEpilepsyFaintingGrowth ProblemsHearing ProblemsHeart MurmurHepatitisHIV/AIDSVaccine InjuryBladder/Kidney ProblemsLatex AllergyLiver ProblemsMeaslesMononucleosisMumpsPregnancy (teens)Rheumatic FeverSeizuresSickle CellThyroid/Endocrine ProblemsTobacco/Drug UseTuberculosisVenereal DiseaseDevelopmental DisabilityBlood TransfusionSeasonal AllergiesEnlarged TonsilsSnoringHeadachesADD/ADHDSpeech ProblemsSkin IssuesSTDVision DisordersOther
Is the patient taking any prescription and or/ OTC medications or vitamin supplements at this time?*

YesNo
List all medications & supplements:*
Is the patient allergic to any medications?*

YesNo
Please list:*
Is the patient allergic to anything else, such as certain foods?*

YesNo
Please list:*
How would you describe the patient's eating habits?*
Has the patient ever had a serious illness?*

YesNo
Please explain:*
Has the patient ever been hospitalized?*

YesNo
Please explain:*
Has the patient ever had sedation or general anesthesia?*

YesNo
Does the patient have any genetic or inherited disorders?*

YesNo
Is the patient physically, mentally, or emotionally impaired?*

YesNo
Please explain:*
Does the patient experience excessive bleeding when cut?*

YesNo
Is the patient currently being treated for any illness?*

YesNo
Please explain:*
Dental History
Is this the patient's first visit to the dentist? If not, when was their last visit?*
Does the patient currently have any dental related pain?*

YesNoNot sureOther
Has the patient had any problems with dental treatment in the past?*

YesNo
Please explain:*
Has the patient had dental xrays taken in the past? If so, when?*
Has the patient ever suffered any injury to the mouth, head, or teeth?*

YesNo
Please explain:*
Has the patient had any problems with the eruption or shedding of teeth?*

YesNo
Please explain:*
Has the patient had any orthodontic treatment?*

YesNo
What type of water does the patient drink?*

CityWellBottledFiltered
Does the patient take fluoride supplements?*

YesNo
Does the patient use fluoride toothpaste?*

YesNo
How often does the patient brush?*
Does the patient floss? If yes, how often?*
Does the patient suck their thumb, fingers, or a pacifier?*

YesNo
Does the patient participate in any sports or other active recreational activities?*

YesNo
Please list any specific concerns you would like to discuss regarding your child's dental health?
By signing below, I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is also my responsibility to inform this office of any changes in my child’s medial status.
Parent's/Guardian's Signature

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Child Health History Form

Medical History

Dental History