Child Health/Dental History Form Patient's Full Name Nickname Date of Birth Parent's Name/Guardian's Name: Relationship to Patient Address: City, State Zip: , Parent's/Guardian's Email Phone Home Work Sex Male Female Have you (the parent/guardian) or the patient had any of the following diseases or problems? Yes No 1. Active Tuberculosis, 2. Persistent cough greater than a three-week duration, 3.Cough that produces bloo If you answer yes to any of the three items above, please stop and call our office. Has the child had any history of, or conditions related to, any of the following: Anemia Cancer Epilepsy HIV +/AIDS Mononucleosis Sickle cell Arthritis Cerebral Palsy Fainting Immunizations Mumps Thyroid Asthma Chicken Pox Growth Problems Kidney Pregnancy (teens) Tobacco/Drug Use Bladder Chronic Sinusitis Hearing Latex allergy Rheumatic fever Tuberculosis Bleeding disorders Diabetes Heart Liver Seizures Venereal Disease Bones/Joints Ear Aches Hepatitis Measles Other Please list the name and phone number of the child's physician: Name of Physician Phone Child's History 1. Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time? Yes No If yes, please list: 2. Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs? If yes, please explain: Yes No 3. Is the child allergic to anything else, such as certain foods? If yes, please explain: Yes No 4. How would you describe the child's eating habits? 5. Has the child ever had a serious illness? If yes, when Please describe: Yes No 6. Has the child ever been hospitalized? Yes No 7. Does the child have a history of any other illnesses? If yes, please list: Yes No 8. Has the child ever received a general anesthetic? Yes No 9. Does the child have any inherited problems? Yes No 10. Does the child have any speech difficulties? Yes No 11. Has the child ever had a blood transfusion? Yes No 12. Is the child physically, mentally, or emotionally impaired? Yes No 13. Does the child experience excessive bleeding when cut? Yes No 14. Is the child currently being treated for any illnesses? Yes No 15. Is this the child's first visit to a dentist? If not the first visit, what was the date of the last dentist visit? Date: Yes No 16. Has the child had any problem with dental treatment in the past? Yes No 17. Has the child ever had dental radiographs (x-rays) exposed? Yes No 18. Has the child ever suffered any injuries to the mouth, head or teeth? Yes No 19. Has the child had any problems with the eruption or shedding of teeth? Yes No 20. Has the child had any orthodontic treatment? Yes No 21. What type of water does your child drink? City Water Well Water Bottled Water Filtered Water 22. Does the child take fluoride supplements? Yes No 23. Is fluoride toothpaste used? Yes No 24. How many times are the child's teeth brushed per day? When are the teeth brushed? Yes No 25. Does the child suck his/her thumb, fingers or pacifier? Yes No 26. At what age did the child stop bottle feeding? Age Breast feeding? Age 27. Does child participate in active recreational activities? Yes No NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to mysatisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form Parent's/Guardian's Signature Date For completion by dentist Comments _________________________________________________________________________________________ For Office Use Only: Medical Alert Premedication Allergies Anesthesia Reviewed by ________________________________________ Date Please enter code above in the field below.