Child Health History Form (Under Age 16)

  • Child Health History Form

  • Date of Birth:*
     / /
  • Sex:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical History

  • Format: (000) 000-0000.
  • Has the patient had any history of, or conditions related to, any of the following?

  • Is the patient taking any prescription and or/ OTC medications or vitamin supplements at this time?*
  • Is the patient allergic to any medications?*
  • Is the patient allergic to anything else, such as certain foods?*
  • Has the patient ever had a serious illness?*
  • Has the patient ever been hospitalized?*
  • Has the patient ever had sedation or general anesthesia?*
  • Does the patient have any genetic or inherited disorders?*
  • Is the patient physically, mentally, or emotionally impaired?*
  • Does the patient experience excessive bleeding when cut?*
  • Is the patient currently being treated for any illness?*

  • Dental History

  • Does the patient currently have any dental related pain?*

  • Has the patient had any problems with dental treatment in the past?*
  • Has the patient ever suffered any injury to the mouth, head, or teeth?*
  • Has the patient had any problems with the eruption or shedding of teeth?*
  • Has the patient had any orthodontic treatment?*
  • What type of water does the patient drink?*
  • Does the patient take fluoride supplements?*
  • Does the patient use fluoride toothpaste?*
  • Does the patient suck their thumb, fingers, or a pacifier?*
  • Does the patient participate in any sports or other active recreational activities?*

  • 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.

     

  • Should be Empty: