Child Health History Form (Under Age 13)

Child Health History Form
Patient's Name: *

First Name Last Name
Nickname:
Date of Birth: *

Month Day Year
Date
Sex: *

M F
1st Parent/Legal Guardian Name: *
Relationship to Patient: *
Phone Number *
2nd Parent/Legal Guardian Name:
Relationship to Patient:
Phone Number
Medical History
Name of Primary Care Physician: *
Phone Number: *
Date of Last Primary Care Visit: *
Has the patient had any history of, or conditions related to, any of the following?

Anemia Arthritis Asthma Bleeding Disorder Bone/Joint Problems Cancer Cerebral Palsy Chicken Pox Chronic Sinusitis Diabetes Ear Aches/Infections Epilepsy Fainting Growth Problems Hearing Problems Heart Murmur Hepatitis HIV/AIDS Vaccine Injury Bladder/Kidney Problems Latex Allergy Liver Problems Measles Mononucleosis Mumps Pregnancy (teens) Rheumatic Fever Seizures Sickle Cell Thyroid/Endocrine Problems Tobacco/Drug Use Tuberculosis Venereal Disease Developmental Disability Blood Transfusion Seasonal Allergies Enlarged Tonsils Snoring Headaches ADD/ADHD Speech Problems Skin Issues STD Vision Disorders
Is the patient taking any prescription and or/ OTC medications or vitamin supplements at this time? *

Yes No
List all medications & supplements: *
Is the patient allergic to any medications? *

Yes No
Please list: *
Is the patient allergic to anything else, such as certain foods? *

Yes No
Please list: *
How would you describe the patient's eating habits? *
Has the patient ever had a serious illness? *

Yes No
Please explain: *
Has the patient ever been hospitalized? *

Yes No
Please explain: *
Has the patient ever had sedation or general anesthesia? *

Yes No
Does the patient have any genetic or inherited disorders? *

Yes No
Is the patient physically, mentally, or emotionally impaired? *

Yes No
Please explain: *
Does the patient experience excessive bleeding when cut? *

Yes No
Is the patient currently being treated for any illness? *

Yes No
Please explain: *
Dental History
Is this the patient's first visit to the dentist? If not, when was their last visit? *
Does the patient currently have any dental related pain? *

Yes No Not sure
Has the patient had any problems with dental treatment in the past? *

Yes No
Please explain: *
Has the patient had dental xrays taken in the past? If so, when? *
Has the patient ever suffered any injury to the mouth, head, or teeth? *

Yes No
Please explain: *
Has the patient had any problems with the eruption or shedding of teeth? *

Yes No
Please explain: *
Has the patient had any orthodontic treatment? *

Yes No
What type of water does the patient drink? *

City Well Bottled Filtered
Does the patient take fluoride supplements? *

Yes No
Does the patient use fluoride toothpaste? *

Yes No
How often does the patient brush? *
Does the patient floss? If yes, how often? *
Does the patient suck their thumb, fingers, or a pacifier? *

Yes No
Does the patient participate in any sports or other active recreational activities? *

Yes No
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

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Child Health History Form

Medical History

Dental History