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

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