Child Health History

Child Health/Dental History
Any information not entered on this form can be collected in the office at time of visit.
Date*
Patients Full Name*

First NameLast Name
Patients Birthdate*

MonthDayYear
Patient's Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Responsible Party (Parents/Legal Guardians)*

Name

Street Address

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Who is responsible for making appointments?*

First NameLast Name
Reason for this Visit*
Has the child had any history of/diffuclty with/ or a diagnosis of any of the following*

AllergiesAnemiaAsthmaCancerDizzinessEpilepsyExcessive BleedingHay FeverHepatitisHead InjuriesHigh Blood PressureHeart DiseaseJaundiceHeart MurmorKidney DiseaseLiver DiseaseMental DisordersNervous DisordersRheumatic FeverRespiratory ProblemsRheumatismStomach ProblemsTuberculosisTumorsUlcersRadiation TreatmentSickle CellThyroidMonoucleosisChicken PoxCerebral PalsyChronic SinusitisDiabetesFood AllergiesHearing ImpairmentHemphilia/Abnormal BleedingHIV/AIDSPersistent CoughRheumatic FeverNONE OF THE ABOVE
Please list all current Medications. If none, enter "NONE."*
Does/Has your child:*

Brush daily?Suck their thumb?Use fluoride toothpaste?Been exposed to x-rays?Been to a dentist before?Have any speech difficulties?Ever sufferd a head injury?Ever recieved a blood transfusion?Ever recieved ortohodontic treatment?Ever been to the hospital?Ever recieved general anesthetic?Chew hard objects (pencils, pens, etc.)?Take fluoride supplements?Grind their teeth?Clench their jaw?Gag easily?Had their tonsils/adenoids removed?NONE OF THE ABOVE
Previous Dentist

Dentist Name

Phone Number

CityState / Province

Postal / Zip CodeCountry
Signature
To be completed in office
Doctor's Signature
To be completed in office
Should be Empty:

Child Health/Dental History