Child Health History Form
Patient's Name
*
Name you like to be called
Age
*
Birthdate
*
-
Month
-
Day
Year
Date
Do you play a musical instrument?
Yes
No
If yes, type:
Girl Scout/Brownies* Troop #
Boy/Cub Scouts* Troop #
School
Parent/Guardian Name
Cell Phone
*
Please enter a valid phone number.
Cell Carrier
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How long at this address?
Previous Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Social Security #
*
Marital Status
*
Email
*
example@example.com
Occupation
Employer
No. of years employed
Who may we thank for referring you to our office?
*
Insurance Information
Primary Insured’s Name
DOB
-
Month
-
Day
Year
Date
Primary Insured’s SS#
Insurance Co:
Insurance Phone
Please enter a valid phone number.
Insurance Co. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured’s Employer
Group #
Do you have dual coverage?
Yes
No
Insured’s Name
DOB
-
Month
-
Day
Year
Date
Insured’s SS#
Insurance Co:
Insurance Phone
Please enter a valid phone number.
Insurance Co. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured’s Employer
Group #
Medical/Dental History
Physician’s Name
Physician’s Phone
Please enter a valid phone number.
Dentist's Name
Dentist's Phone
Please enter a valid phone number.
Are you currently under any medical treatment?
*
Yes
No
If yes, please explain
Do you have pain, clicking, and/or popping noises in the jaw?
*
Yes
No
If yes, please explain
Are you aware of either clenching or grinding of teeth?
*
Yes
No
If yes, please explain
Do you have frequent headaches?
*
Yes
No
If yes, how often?
Do you have ear problems? (Aches, ringing, dizziness, fullness)
*
Yes
No
If yes, please explain
Do you have difficulty breathing through the nose?
*
Yes
No
If yes, please explain
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?
*
Yes
No
If yes, please explain
Do you have speech problems, or are you in speech therapy?
*
Yes
No
If yes, please explain
Have you had your tonsils and/or adenoids removed?
*
Yes
No
If yes, please explain
Has there been any history of:
*
Joint swelling
Asthma
TB
Aids
Kidney
Liver Condition
Epilepsy
Rheumatic fever
None
Other
Do you bleed easily?
*
Yes
No
If yes, please explain
Is there a tendency to faint or become dizzy?
*
Yes
No
If yes, please explain
Do you have allergies? (Sulphur, penicillin, novocain, etc.)
*
Yes
No
If yes, please explain
Are you currently taking any medication?
*
Yes
No
If yes, please list
Do you have a heart condition?
*
Yes
No
Do you pre-medicate?
*
Yes
No
No Cardiologist
Do you have sleep apnea?
*
Yes
No
If yes, please explain
Do you smoke or chew tobacco?
*
Yes
No
If yes, please explain
Have there been any injuries to the teeth?
*
Yes
No
If yes, please explain
Have you had any permanent teeth extracted?
*
Yes
No
If yes, please explain
Have we treated any other family members?
*
Yes
No
If yes, who
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: