Cricket Lane Dental Page 1 of 2
Health History Form - Child
Patient’s Name: ______Date of Birth: ______
Person Completing Form:______Today’s Date:______
Medical History
Please mark if your child has any history or conditions related to any of the following:
Anemia □ / Cancer □ / Epilepsy □ / HIV/AIDS □ / Mono □ / Thyroid □Arthritis □ / Cerebral
Palsy □ / Fainting □ / Immunizations□ / Mumps □ / Tobacco □
Asthma □ / Chicken Pox □ / Growth Problems □ / Kidney □ / Pregnancy (teens) □ / Drug Use □
Bladder □ / Chronic Sinusitis □ / Hearing □ / Latex Allergy □ / Rheumatic Fever □ / TB □
Bleeding Problems □ / Diabetes □ / Heart □ / Liver □ / Seizures □ / STDs □
Bones or Joints □ / Ear Aches □ / Hepatitis □ / Measles □ / Sickle Cell □ / Other:______
Please list any other medical conditions your child has: ______
______
Child’s Doctor: ______Phone:______
Is your child taking any prescription or over the counter medications or vitamin supplements? ____ Yes _____ No
If yes, please list: ______
______
Does your child have any allergies to medications? ____ Yes _____ No
If yes please list: ______
Does your child have allergies to food or environmental allergies? _____ Yes ____ No
If yes, please list: ______
Has your child ever had a serious illness or been hospitalized? _____ Yes ____ No
If yes please explain: ______
______
Has your child ever had surgery? _____ Yes _____ No If yes, please describe: ______
______
Is your child currently being treated for any illnesses? ____ Yes ____ No
Has your child ever received a blood transfusion? ____ Yes ____ No
Does your child have excessive bleeding when cut? ____ Yes ____ No
Does your child have any speech difficulties? ____ Yes ____ No
Does your child have any inherited problems? ____ Yes ___ No
Does your child have any physical, mental or emotional problems? ____ Yes ____ No
How would you describe your child’s eating habits? ______
______
Dental History
Is this your child’s first visit to the dentist? ____ Yes ____ No If not, date of last visit: ______
Has your child had any problems with dental treatment in the past? ____ Yes ____ No
Has your child ever had any dental xrays? ____ Yes ____
Has your child ever had any injuries to the mouth, head or teeth? ___ Yes ____ No
Has your child ever seen an orthodontist? ____ Yes ____ No
What type of water does your child drink? ____City Water ____ Well Water ____ Bottled Water ____ Filtered Water
Does your child take fluoride treatments? ____ Yes ____ No
Is fluoride toothpaste used? ____ Yes ____ No
How many times per day are your child’s teeth brushed? ______Who brushes your child’s teeth? ______
Does your child suck his/her thumb, fingers, or pacifier? ___ Yes ___ No
At what age did your child stop taking a bottle? ______Breastfeeding? _____
Does your child participate in any sports or recreational activities? ____ Yes ____ No
Is there any other information you would like the dentist to know about your child? ______
______
______
I certify that I have read and completed this health history form accurately. I understand that it is important to give a truthful and complete health history and that my dentist and his staff will rely on this information when treating my child. I will not hold my dentist liable for information that I have omitted or errors I have made on this form.
Parent or Guardian
Printed Name: ______Signature:______
Today’s Date:______
Health History Review:
Please review this form and select a box. Please mark and date any changes on the form above.
____ My Health History has not changed since my last visit____ My Health History has changed since my last visit
Date:______Initials of patient______/ ____ My Health History has not changed since my last visit
____ My Health History has changed since my last visit
Date:______Initials of patient______
____ My Health History has not changed since my last visit
____ My Health History has changed since my last visit
Date:______Initials of patient______/ ____ My Health History has not changed since my last visit
____ My Health History has changed since my last visit
Date:______Initials of patient______
For Staff Use
Reviewed by:
Initials/Date: ______Initials/Date:______Initials/Date:______
Initials/Date: ______Initials/Date:______Initials/Date:______Initials/Date: ______Initials/Date:______Initials/Date:______
Revised 10/31/10