Child Health History Form
Patient's Name
*
First Name
Last Name
Preferred Name
Parent or Guardian's Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date
Sex
Height
Weight
School
Grade Level
Whom may we thank for referring you to our office?
Preferred Office Location
*
Please Select
South Lakeland
North Lakeland
Brandon
Bartow
Riverview
Town 'n' Country/Westchase
Winter Haven
Trinity
Palm Harbor
Wesley Chapel
Financially Responsible Party
Primary Fin. Party
First Name
Last Name
Marital Status
Please Select
Married
Single
Divorced
Widowed
Residence (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address?
Previous Address (If less than 3 years.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Social Security #
Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient
Relationship to Patient
Employer
Occupation
No. Years Employed
Secondary Fin. Party
First Name
Last Name
Employer
Occupation
No. Years Employed
Phone Number
Please enter a valid phone number.
Social Security #
Birthdate
-
Month
-
Day
Year
Date
Insurance Information
Policy Holder's Name
First Name
Last Name
Policy Holder's SSN
Phone Number
Please enter a valid phone number.
Policy Holder's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Name
Insurance Company
Policy ID #
Policy Holder's Name
First Name
Last Name
Policy Holder's SSN
Employer Name
Insurance Company
Policy ID #
Group No.
Insurance Co. Phone
Please enter a valid phone number.
Do you have dual coverage?
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's SSN
Employer Name
Insurance Company
Policy ID #
Group No.
Insurance Co. Phone
Please enter a valid phone number.
Emergency Information
Name of nearest relative not living with you
*
First Name
Last Name
Complete Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Medical History
Name of Family Physician
Last visit to this Dr.
-
Month
-
Day
Year
Date
MD Specialist you see regularly
Speciality
Under Medical Treatment now?
*
Yes
No
If yes, for what?
Taking medication now?
*
Yes
No
If yes, for what?
List Medication:
History Of:
*
Yes
No
Explanation
Heart Disease or Diabetes
Cancer or skin cancer
High Blood Pressure
Allergies or Asthma
Hepatitis
Positive HIV
Bleeding disorder or Epilepsy
Kidney or Liver Disease
Reaction to Anesthetc
Reaction to Antbiotics
Dental History
Family Dentist
Last Dental Visit
-
Month
-
Day
Year
Date
How many times a day do you brush?
How many times a day do you floss?
Patient's chief concern
Dentist's chief concern
Who 1st noticed the problem?
Have you ever had:
*
Yes
No
Explanation
Injury to teeth
Injury to face
Stammer or Lisp
Mouth Breathing
Severe Headaches
Jaw Joint Pain
Thumb or Finger Sucking
Did parents have braces?
Previous dental treatment:
*
Yes
No
Endodontic (root canal) Tx
Oral Surgery (jaw surgery) Tx
Orthodontic (braces) Tx
Periodontal (gums) Tx
Brother(s) & Sister(s) names and DOB(s):
Orthodontic problems or previous treatment:
Signature
I understand that where appropriate, credit bureau reports may be obtained.
Yes
No
Parent or Guardian's Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: