www.dentistryatlasalle.com - CHILDREN'S MEDICAL HISTORY FORM

CHILDREN'S MEDICAL HISTORY FORM
In order to render optimum health care service, it is necessary to become acquainted with the vital information related to each patient. Of course, all information is strictly confidential. Although some questions may seem unimportant at the moment, they may be vital in case of emergency. Therefore PLEASE ANSWER EVERY QUESTION. Please feel free to ask the receptionist for help in completing this form.
PERSONAL INFORMATION
Date*

MonthDayYear
Date
Child’s Full Name *

First NameLast Name
Nickname
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Age*
Gender / Title*
Birth Date*

MonthDayYear
Date
School
Grade
Whom may we thank for referring you?
Father’s Name
Occupation/Employed by
Bus. Phone

Area CodePhone Number
Mother’s Name
Occupation/Employed by
Bus. Phone

Area CodePhone Number
Do we need to send the insurance claims on your behalf?*

YesNo
Dental Ins. Co.
% covered
Group No.
Cert. or ID No.
Name of parent responsible for account
MEDICAL HISTORY
Child’s Physician
Phone Number

Area CodePhone Number
Is child now under the care of a physician?*

YesNo
If so, explain *
Has child ever had any serious illness or been treated in the hospital?*

YesNo
If so, explain *
Is child now taking any medicine?*

YesNo
What*
Is child allergic to any medicine or food?*

YesNo
List*
Has child ever had any unfavourable reaction to any previous medical or dental care?*

YesNo
Has child ever had any of the following conditions? (please ✓ any that apply)*

MeaslesShortness of breathBlood DiseaseMumpsLung DiseaseDiabetesChicken PoxFainting spellsEpilepsyScarlet FeverAnkle swellingJaundiceStrep ThroatPains in chestKidney DiseaseTonsillitisHeart TroubleLiver DiseaseEar AchesRheumatic feverTuberculosisHay feverBruise easilyNervous DisorderAsthmaProlonged bleedingPsychiatric careMuscular DystrophyMultiple SclerosisAIDS or HIV+NoneAutre
DENTAL HISTORY
Has child had previous dental care?*

YesNo
If so, how long ago?*
Has child ever had an accident, injury or surgery about the mouth?*

YesNo
If yes, describe*
Has child ever had an unpleasant experience associated with a dental visit?*

YesNo
If yes, describe*
Is the child particularly nervous about visiting the dentist?*

YesNo
Have child’s teeth ever been treated with decay-preventing Fluoride?*

YesNo
Has child ever had Orthodontic treatment?*

YesNo
Does child have any oral habits such as:*

Thumb suckingNail bitingFinger suckingMouth breathingLip BitingTeeth grindingTongue ThrustingNoneAutre
Is there a family history of:*

High decay RateExtra teethGum diseaseMissing teethMalformed teethCrooked teethNone
How often does your child brush his or her teeth?*
Additional Information
AUTHORIZATION
I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical and dental histories are correct to the best of my knowledge. I understand that my dental insurance (if insured) is a contract between the insurance carrier and me and not between the insurance carrier and the dentist and that I am still responsible for all the dental fees. I understand that I will be charged for all dental treatment and that any payments received by the Dental Office from my insurance company will be credited to my account or refunded to me if I have paid the dental fees incurred.
PARENT’S CONSENT FOR CHILDREN UNDER 18
I hereby consent to the performing of the Dental and Oral Surgery procedures necessary or advisable for my children, including the use of Local Anesthesia and/or Relative Analgesia, as indicated, and I accept responsibility for the fee.
Parent’s Signature *

Effacer
Parent's Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

CHILDREN'S MEDICAL HISTORY FORM

PERSONAL INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

AUTHORIZATION

PARENT’S CONSENT FOR CHILDREN UNDER 18