Pediatric Dentistry Health History Form
MEDICAL AND DENTAL HISTORY
Careful completion of this form will assist us in providing your child with the best possible dental care,
Child's Name ______
Prefers to be called ______
School______
Home Address: ______
City ______
Date of Birth ____/____/______
Grade______
Zip ______Phone______
Mother's Name ______
Work Address ______
Father's Name ______
Work Address ______
Occupation ______
Phone ______
Occupation ______
Phone ______
Legal Guardian(s)______
Email address (optional) ______
Child’s favorite hobbies______
Names and ages of siblings ______
How did you hear about us______
INSURANCE INFORMATION
Dental Insurance1______Dental Insurance 2______
Policy Holder 1______Policy Holder 2______
Social security number 1 ______Social Security number 2______
DOB 1 ______DOB 2 ______
MEDICAL HISTORY
Child's Physician______
Phone#______City, State
Address______City______State ______
Date of Last Physical Examination______
Is your child being treated by a physician at this time?...... YESNO
If yes, why?______
Is your child taking any medications at this time?...... YESNO
If yes, what and why?______
Has your child ever been hospitalized?...... YESNO
If yes, why and when?______
Has your child had any operations?...... YESNO
If yes, why and when?______
Has your child ever had general anesthesia?...... YESNO
If yes, were there any complications? ______
______
Is your child allergic to anything? (Medications, Food, Latex, Metals, Dyes,Other )...... YESNO
If yes, what? ______
Has your child ever been given antibiotics?...... YESNO
If yes, were there any complications?______
Is your child up to date on his/her immunizations?...... YESNO
MEDICAL HISTORY
Organs and Systems: Has your child ever had any treatment for any of the following? Please check yes or no:
YESNOYESNO
…………Blood – Circulatory…………Heart
…………Bones…………Liver
…………Endocrine Glands…………Musculoskeletal
…………Eyes, Ears, Nose, Throat…………Nervous System
…………Gastrointestinal…………Skin
…………Kidney / Bladder
If yes to any of the above, please elaborate.______
______
______
Illness: Has your chiId ever been diagnosed as having any of the following conditions? Please check yes or no:
YesNoYesNo
Anemia…….……..Heart Disease…….……
Allergy…….……..Hemophilia…….……
Arthritis…….……..Hepatitis-Type………….……
Asthma…….……..Immune Deficiency…….……
Autism…….……..Jaundice…….……
Brain Injury…….…….Learning Disability…….……
Cancer…….…….Leukemia…….……
Cerebral Palsy…….…….Mental Retardation…….……
Chicken Pox…….…….Nutritional Deficiency…….……
Cleft Lip/Palate………….Orthopedic problems…………
Cystic Fibrosis………….Rheumatic Fever…………
Convulsions………….Scoliosis…………
Diabetes………….Sickle Cell Anemia…………
Eye Problems………….Spina Bifida…………
Excess Bleeding………….Tetanus…………
Fainting…….…….Whooping Cough…………
Hearing Loss…….…….Other
DENTAL HISTORY
Is this your child's first dental visit?...... YES NO
Reason for bringing child for this visit?______
______
Name of child's previous dentist ______Date of last visit______
Has your child had dental radiographs (x-rays)?...... YESNO
If yes, when were they last taken?______
Has your child ever had local anesthesia? (Novocaine)...... YESNO
If yes, were there any complications?______
Has your child ever been sedated or received general anesthesia? ...... YES NO
Please indicate if your child has or has had any of the following oral habits:
Breathes through mouth...... YESNO
Sucks thumb or finger...... YESNO
Uses a pacifier...... YESNO
Bites or sucks lips...... YESNO
Tongue habit...... ;..YESNO
Bottle to bed...... YESNO
Other ______
If yes, until what age?______
If yes, until what age?______
If yes, until what age?______
Do you live in a community with fluoridated water?...... YESNO
Does your child drink tap water?...... YESNO
Does your child use any fluoride supplements? (Rinses, vitamins)………………………………………………YES NO
If yes, name of product ______
How often does your child brush his/her teeth?______
When? ______
Brand of toothpaste? ______
Type of toothbrush: Manual, powered, soft or hard bristles______
Does your child floss his/her teeth?...... YESNO
When?______
Is there parental assistance or supervision when:
Brushing?...... YESNO
Flossing?...... YESNO
History of cavities in the family______
History of missing or extra teeth______
Additional remarks______
THE SIGNATURE OF A PARENT OR GUARDIAN BELOW AUTHORIZES THE INITIAL CHECKUP AND THE FILING OF INSURANCE CLAIMS. YOU WILL BE ASKED TO SIGN SEPARATE INFORMED CONSENTS FOR FURTHER TREATMENTS.
SIGNATURE ______
DATE ______
RELATIONSHIP______
Please bring this completed form to your child's initial appointment.