Child Health & Dental History Form

Child Health & Dental History Form

CAREFUL COMPLETION OF THIS FORM WILL ASSIST US IN PROVIDING YOUR CHILD WITH THE BEST POSSIBLE DENTAL CARE.
Personal Information
Child's Name*

First NameLast Name
Gender*

MaleFemaleOther
What name does your child prefer to be called?
Child's Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Parent/Guardian's Name*

First NameLast Name
Name of emergency contact*

First NameLast Name
Emergency contact phone number*
Please enter a valid phone number.
Relationship of emergency contact to child*
Health Care Providers
Does you child have a family physician?*

YesNo
If yes, name of physician

First NameLast Name
Does your child have a dentist?*

YesNo
If yes, name of dentist

First NameLast Name
Dental Insurance
Does your child have coverage through dental insurance?*

YesNo
If yes, name of policy holder

First NameLast Name
Birth date of policy holder

MonthDayYear
Date
Name of insurance company
i.e. Manulife, Sunlife, Canada Life etc
Policy number (group number)
Subscriber number (member ID)
Medical Information
Is your child being treated by a health care provider for any medical conditions?*

YesNo
If yes, please explain:
Has there been any changes in your child's health in the past year?*

YesNo
If yes, please explain:
When did your child last visit their physician?*
mm/yyyy
Is your child taking any prescriptions, over the counter medications, herbal supplements or vitamins?*

YesNo
If yes, please provide names of medications/supplements with their dosages
Is your child allergic to any medications: i.e. antibiotics or other drugs?*

YesNo
If yes, please explain:
i.e. name of medication and describe reaction
Has your child ever had a peculiar or adverse reaction to any medicines or injections?*

YesNo
If yes, please explain:
Is your child allergic to anything else? (i.e. foods/chemicals/environmental)*

YesNo
If yes, please explain
i.e. what is the allergy and reaction
Has your child ever needed to take antibiotics before his/her dental appointments?*

YesNo
Does your child have or ever had a replacement or repair of a heart valve or infection of the heart or a heart condition from birth?*

YesNo
If yes, please explain:
Has your child ever been hospitalized?*

YesNo
If yes, when were they hospitalized and why?
Has your child had a history of, or a condition related to, any of the following. Please check all those that apply.*

AnemiaArthritisAsthmaAutismBirth DefectsBladderBleeding problem/disorder?Bones/jointsBulemia/anorexiaCancer/leukemiaCerebral PalsyChicken PoxChronic SinusitisCold soresDiabetesDowns SyndromeEar achesEpilepsyFaintingGERD/acid refluxGrowth problemsHearingHeartHepatitisHigh/low bloodpressureHyperactivity/ADHDKidneyLatex allergyLiverMeaslesMononucleosisMouth ulcersMumpsPregnancy (teens)Prosthetic/artificial joints?Rheumatic feverSeizuresSkin disordersSleep apnea/snoringThyroidTobacco/Drug useTuberculosisVeneral diseaseNone of the aboveOther
Has your child had any history of any other illnesses?*

YesNo
If yes, please explain:
Does your child have any conditions or therapies that could affect his/her immune system? ie: Aids/HIV. Chemotherapy or radiation treatments?*

YesNo
Does your child have any inherited problems?*

YesNo
If yes, please explain:
Does your child have any speech or hearing difficulties?*

YesNo
If yes, please explain:
Does your child experience excessive bleeding when cut?*

YesNo
Dental History
Is this your child's first visit to a dental health care provider?*

YesNo
If not the first visit, what was the date of their last dental visit?

MonthDayYear
Date
Has your child ever had any dental x-rays?*

YesNo
If yes, when were they taken?
mm/yyyy
Has your child had any problems with dental treatments in the past?*

YesNo
If yes, please explain:
How do you think your child will react to this dental visit?*

Co-operativeUn-cooperativeUnsure
Has your child ever suffered any injuries to their head, mouth or teeth?*

YesNo
If yes, please explain:
What happened and when? What was the result of the injury?
Has your child had any issues with eruption or shedding of teeth?*

YesNo
If yes, please explain:
Has your child ever had any cavities?*

YesNoNot sure
Has your child had any orthodontic treatment?*

YesNo
If yes, what type of treatment? For how long?
e.g. braces, appliances, space maintainers, guards?
What type of water does your child drink?*
How would you describe your child's eating habits?*
e.g. good with lots of fruits and veggies? high sugar intake, juices, pop, gum chewing, candies, etc
Does your child take fluoride supplements?*

YesNo
Is fluoride toothpaste used?*

YesNo
Do you prefer a natural approach for your child's dental care? e.g. no fluorides, antibacterial products etc.*

YesNoOther
How frequently does your child brush OR get his/her teeth brushed?*
What type of toothbrush?*
How frequently does your child clean between their teeth OR get help to clean between their teeth?*
What aid is used to clean between their teeth?*
Does the child suck on his/her thumb, fingers or pacifier?*

YesNo
Any other habits I should be aware of....please discuss below
At what age did your child stop bottle feeding?*
At what age did your child stop breastfeeding?*
Please list some of your child's interests or hobbies*
Is there anything else you want me to be aware of regarding your child's dental health or treatment?
Consent for Treatment & Privacy Policy

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history on behalf of my child. I have not knowlingly omitted any information. I have had the opportunity to ask questions and receive answers regarding the medical-dental history.

Should there be any change in either my child's health status or any other information I have provided, I will advise the dental hygienist.

I authorize the provider, (dental hygienist) to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment for my child. I understand this action will give my consent verbally.

I understand the information provided from or to my child's medical doctor, dentist or another health care provider may be necessary.

I give permission to the dental hygienist to correspond through a phone call, text or email communication, if necessary, with me or my child's health care provider. I am aware, although necessay precautions are in place to protect my child's personal, medical and dental information, communication through email, phone or text may not be entirely secure.

I have had the opportunity to ask questions and have been advised of the privacy policy of the office and that my child's personal information will be collected, used and disclosed within the guidelines of the policy
Name of parent/guardian*

First NameLast Name
Date*

MonthDayYear
Date
Signature parent/guardian*

Clear
Should be Empty:

Child Health & Dental History Form

Personal Information

Health Care Providers

Dental Insurance

Medical Information

Dental History