Child Health History Form (Updated)

Child Health History Form
Patient Preferred Name*
Patient Preferred Pronouns*
Patient Full Name*
Patient Nickname
Patient Birth Date*

MonthDayYear
Date
Sex Assigned at Birth*

MaleFemale
Patient Age*
School (If currently a student)
Grade
Siblings Names & Ages
Patient Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
General Dentist
Office Phone

Area CodePhone Number
Who can we thank for referring you to our office if other than your dentist?
Responsible Party Information

Parent/Guardian information is required if patient not responsible. The office reserves the right to verify the credit status of potential patients seeking payment terms.
Parent 1 OR Responsible Party Name*
Marital Status*

MarriedDivorcedWidowedSinglePartnership
Address (if different than Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email*
example@example.com
SSN (Must be provided to verify orthodontic insurance coverage)*
Birth Date*

MonthDayYear
Date
Employer
Occupation
Years Employed
Parent 2 OR Responsible Party Name
Marital Status

MarriedDivorcedWidowedSinglePartnership
Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
SSN (Must be provided to verify orthodontic insurance coverage)
Birth Date

MonthDayYear
Date
Employer
Occupation
Years Employed
Dental Insurance Information

(Please provide copy of insurance card to office)
Do you have DENTAL Insurance?*

YesNo
Primary Insurance Company*
Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone*

Area CodePhone Number
Name of Employer*
Group No.*
ID #*
Employee Name*
Date of Birth*

MonthDayYear
Date
Employee Home Address (If different than patient)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee relationship to patient*
Employee Social Security #*
Upload photo of front and back of insurance card*

Browse Files

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Do you have Secondary Insurance?*

YesNo
Secondary Insurance Company*
Insurance Co. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone*

Area CodePhone Number
Name of Employer*
Group No.*
ID #*
Employee Name*
Date of Birth*

MonthDayYear
Date
Employee Home Address (if different than patient)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee relationship to patient*
Employee Social Security #*
Upload photo of front and back of insurance card*

Browse Files

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Emergency Contact
Name of emergency contact (not living in your home)*
Phone*

Area CodePhone Number
Complete Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
Medical History
Is this patient in good health?*

YesNo
Primary Physician*
Medical Specialist(s) *
Is your child being treated by a physician at this time? (Include reason) *
Is your child taking any medications? (If so, please list) *
Known allergy or sensitivity to latex? *
Known allergy or sensitivity to metals?*
List any known allergies: *
Is your child up to date on immunizations against childhood diseases?*

YesNo
Please mark yes or no for each of the following, if you answered yes to any question, please provide details in space below question. Does your child have or have a history with any of the following:
Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions*

YesNo
If yes, please explain:
Problems with physical growth or development*

YesNo
If yes, please explain:
Large tonsils (tonsils or adenoids removed), sleep apnea, snoring, or mouth breathing*

YesNo
If yes, please explain:
Excessive gagging*

YesNo
If yes, please explain:
Asthma*

YesNo
If yes, please explain:
RSV*

YesNo
If yes, please explain:
Diabetes, hyperglycemia, or hypoglycemia*

YesNo
If yes, please explain:
Congenital heart defect/disease, murmur, rheumatic fever/heart disease*

YesNo
If yes, please explain:
High blood pressure*

YesNo
If yes, please explain:
Frequent cold/cough, pneumonia*

YesNo
If yes, please explain:
Hepatitis or Liver problems*

YesNo
If yes, please explain:
GERD, reflux, or gastrointestinal issues*

YesNo
If yes, please explain:
Concerns with weight or eating disorders*

YesNo
If yes, please explain:
Bladder or kidney problems*

YesNo
If yes, please explain:
Anemia or prolonged bleeding*

YesNo
If yes, please explain:
Endocrine, thyroid, or pituitary problems*

YesNo
If yes, please explain:
Bone, muscle, or joint problems*

YesNo
If yes, please explain:
Impaired vision, hearing, or speech*

YesNo
If yes, please explain:
Developmental, behavioral, or learning disorders*

YesNo
If yes, please explain:
Epilepsy*

YesNo
If yes, please explain:
ADD/ADHD*

YesNo
If yes, please explain:
Autism spectrum disorder*

YesNo
If yes, please explain:
Fainting, dizziness, or recurrent headaches*

YesNo
If yes, please explain:
Cancer*

YesNo
If yes, please explain:
Mononucleosis (Mono)*

YesNo
If yes, please explain:
Tuberculosis (TB)*

YesNo
If yes, please explain:
Sexually transmitted disease (STD)*

YesNo
If yes, please explain:
HIV/AIDS*

YesNo
If yes, please explain:
Hospitalizations or surgeries*

YesNo
If yes, please explain:
Any other significant medical history:*
Has patient reached puberty?*

YesNo
If yes:
If male, has voice changed?

YesNo
If female, has menstruation started?

YesNo
Date

MonthDayYear
Date
If female, is patient pregnant?

YesNo
Dental History
What concerns you most about your teeth and facial appearance? *
How would you describe your child’s oral health?*
Have there been injuries to the face, mouth or teeth?*

YesNo
Does your child grind or clench their teeth?*

YesNo
Has the patient ever sucked a thumb or finger?*

YesNo
If yes, until what age?
Does the patient have any speech problems?*

YesNo
Have you been informed of any missing or extra teeth?*

YesNo
Has an orthodontist been consulted previously?*

YesNo
Has patient had previous orthodontic treatment?*

YesNo
Have other members of your family had orthodontic treatment?*

YesNo
Has anyone in your family been seen in our office? Name(s)*
Does anyone in your family have a similar dental problem?*
Has your child had a negative dental experience?*
Signature

The above information is correct to the best of my knowledge.
Signature*

Clear
Date Submitted*

MonthDayYear
Date
Should be Empty:

Child Health History Form

Responsible Party Information

Dental Insurance Information

Emergency Contact

Medical History

Dental History

Signature