Child Health / Dental History Form

Patient (Child) Information

Child's First Name *

Child's Last Name *

Child's Date of Birth * 🛈 +

Nickname

Child's Gender *

Male

Female

Child's Primary Street Address *

Address Line 2

City *

State *

Zip Code *

Name of Pediatrician

Pediatrician phone number

Name of alternate physician / specialist

Alternate physician phone number

First Parent Information

Relationship *

Mother	Father	Legal Guardian
Parent (Non-gender specific)

First Name *

Last Name *

Same address as child? *

Yes - Skip address fields below

No - Complete address fields below

Street Address

Address Line 2

City

State

Zip Code

Cell Phone Number *

Home Phone Number

Email Address *

Preferred methods to confirm appointments (you can select more than one) *

Email

Phone call

Text

Postal mail

How did you hear about us (select all that apply) *

If you were referred by someone, please share their name

Additional Parent Information

Relationship

Mother	Father	Legal Guardian
Parent (Non-gender specific)

First Name

Last Name

Same address as child?

Yes - Skip address fields below

No - Complete address fields below

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Preferred methods to confirm appointments (you can select more than one)

Email

Phone call

Text

Postal mail

Health Conditions

Please review carefully and check the box if your child had any history of, or condidition related to, any of the following:

ADHD / ADD	Anemia	Asthma	Autism
Bladder/Kidney	Bleeding disorders	Bone disorders	Cancer
Cerebral Palsy	Chicken Pox	Chronic Sinusitis	Diabetes
Ear Aches/Infection	Enlarged tonsils	Epilepsy/Seizures	Fainting
Growth Problems	Headaches	HIV+/AIDS	Hyperactivity
Latex Allergy	Liver/Hepatitis	Measles	Mononucleosis
Mumps	Pregnancy	Rheumatic Fever	Sickle Cell
Snoring	Speech/Hearing	Skin	Thyroid
Tobacco/Drug Use	Tuberculosis	STD	Vision Disorders

Please list any other conditions we should be aware of

Is your child taking any medications (prescription, over-the-counter, vitamin supplements, etc.)? If yes, please list. *

No

Yes Yes

Is your child allergic to any medications? If yes, please list. *

No

Yes Yes

Is your child allergic to any foods? If yes, please list. *

No

Yes Yes

Is your child allergic to any metals? If yes, please list. *

No

Yes Yes

Does your child have seasonal allergies? If yes, please list. *

No

Yes Yes

Does your child have any other allergies? If yes, please list. *

No

Yes Yes

Has your child ever been hospitalized or had any type of surgery? If yes, please explain. *

No

Yes Yes

Does your child have any mental, developmental, or physical impairments? If yes, please explain. *

No

Yes Yes

Has your child ever received sedation or general anesthesia? If yes, did you child experience any complications (please explain)? *

No

Yes Yes

Has your child ever experienced excessive bleeding when cut or injured? If yes, please explain. *

No

Yes Yes

Does your child have any genetic or inherited disorders? If yes, please explain. *

No

Yes Yes

Is your child being treated for any other illnesses not yet discussed on this form? If yes, please explain. *

No

Yes Yes

Are your child's immunizations up to date? If no, please explain. *

Yes

No No

Dental Experience

Is this your child's first dental visit? If not, list the date of last visit. *

Yes

No No

Has your child ever had an unfavorable experience or reaction to a previous dental visit? If yes, please explain. *

No

Yes Yes

Have there ever been any injuries to your child's mouth, teeth, or head? If yes, please explain. *

No

Yes Yes

What type of water does your child drink most? *

City (tap) water

Bottled water

Filtered water

Does your child take fluoride supplements? *

No

Yes

Does your child use fluoride toothpaste? *

No

Yes

How many times are your child's teeth brushed per day on average? *

Is the brushing supervised and/or assisted? *

No

Yes

If yes, are you interested in learning more about sports guards?

No

Yes

Has your child complained of any recent dental pain? If yes, please explain. *

No

Yes Yes

Any other dental concerns/comments not yet discussed on this form? If yes, please explain. *

No

Yes Yes

Please answer the following questions regarding past and current feeding and other habits.

Breast-feeding *

Past

Current

Never

Age when stopped breast-feeding

Bottle use *

Past

Current

Never

Age when stopped bottle use

Sippy cup use *

Past

Current

Never

Age when stopped sippy cup use

Thumb/finger sucking *

Past

Current

Never

Age when stopped thumb/finger sucking

Pacifier use *

Past

Current

Never

Age when stopped pacifier use

Teeth grinding/clenching *

Past

Current

Never

Age when stopped teeth grinding/clenching

Signature

As this child's parent or legal guardian, I confirm that the completed information in this form is correct to the best of my knowledge. I understand that misrepresenting or withholding medical or dental information can be harmful to my child during treatment.

Sign below using your mouse on a computer or finger on a tablet. *

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First Name *

Last Name *

Today's Date * 🛈 +

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