Child Health History Form (Under Age 16)

Child Health History Form
Patient's Name:*

First NameLast Name
Nickname:
Date of Birth:*

MonthDayYear
Date
MaleFemale
1st Parent/Legal Guardian Name:*
Relationship to Patient:*
Phone Number*
Format: (000) 000-0000.
2nd Parent/Legal Guardian Name:
Relationship to Patient:
Phone Number
Format: (000) 000-0000.
Medical History
Name of Primary Care Physician:*
Phone Number:*
Format: (000) 000-0000.
Date of Last Primary Care Visit:*
AnemiaArthritisAsthmaBleeding DisorderBone/Joint ProblemsCancerCerebral PalsyChicken PoxChronic SinusitisDiabetesEar Aches/InfectionsEpilepsyFaintingGrowth ProblemsHearing ProblemsHeart MurmurHepatitisHIV/AIDSVaccine InjuryBladder/Kidney ProblemsLatex AllergyLiver ProblemsMeaslesMononucleosisMumpsPregnancy (teens)Rheumatic FeverSeizuresSickle CellThyroid/Endocrine ProblemsTobacco/Drug UseTuberculosisVenereal DiseaseDevelopmental DisabilityBlood TransfusionSeasonal AllergiesEnlarged TonsilsSnoringHeadachesADD/ADHDSpeech ProblemsSkin IssuesSTDVision DisordersOther
YesNo
List all medications & supplements:*
YesNo
Please list:*
YesNo
Please list:*
How would you describe the patient's eating habits?*
YesNo
Please explain:*
YesNo
Please explain:*
YesNo
YesNo
YesNo
Please explain:*
YesNo
YesNo
Please explain:*
Dental History
Is this the patient's first visit to the dentist? If not, when was their last visit?*
YesNoNot sureOther
YesNo
Please explain:*
Has the patient had dental xrays taken in the past? If so, when?*
YesNo
Please explain:*
YesNo
Please explain:*
YesNo
CityWellBottledFiltered
YesNo
YesNo
How often does the patient brush?*
Does the patient floss? If yes, how often?*
YesNo
YesNo
Please list any specific concerns you would like to discuss regarding your child's dental health?
By signing below, I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is also my responsibility to inform this office of any changes in my child’s medial status.
Parent's/Guardian's Signature
Should be Empty:

Child Health History Form

Medical History

Dental History