Dr. Cruz Pediatric Health History

Tell Us About Your Child:

Child’s Name:*

First Name Middle Name Last Name

Child’s Birth date:*

Date

Child’s Age: *

Child’s Home Phone #:*

Social Security #:

Nickname:

*

MaleFemale

School:

Grade:

Child’s Home Address:*

Street Address

Street Address Line 2

City State

Zip Code

Name:*

First Name Middle Name Last Name

Relationship:*

Do you have legal custody of this child?

YesNo

Is the child adopted?

YesNo

Is the child in a foster home?

YesNo

Whom may we Thank for referring you?

Other siblings seen by us:

Neighbor or Relative not living with you

His/ Her Name:

First Name Middle Name Last Name

Relationship:

Address

Street Address

Street Address Line 2

City State

Zip Code

Work Phone #:

Home Phone #:

Parent’s Marital Status:*

Mother:

MotherStep MotherGuardian

Birth date

Date

Home Phone #:

Work Phone #:

Address

Street Address

Street Address Line 2

City State

Zip Code

Name

First Name Middle Name Last Name

Social Security #:

Driver’s License #:

Employer:

Length of Employment:

Father:

FatherStep FatherGuardian

Birth date

Date

Home Phone #:

Work Phone #:

Address

Street Address

Street Address Line 2

City State

Zip Code

Name

First Name Middle Name Last Name

Social Security #:

Driver’s License #:

Employer:

Length of Employment:

Name*

First Name Middle Name Last Name

Relationship: *

Address*

Street Address

Street Address Line 2

City State

Zip Code

Work Phone #:

Home Phone #:

Driver’s License #:

Social Security #:

Employer:

Who is responsible for making appointments?

Name*

First Name Middle Name Last Name

Work Phone #:

Home Phone #:

Best Time to call:*

Primary Insurance

Dental Coverage?

YesNo

Medical Coverage

YesNo

Orthodontic Coverage?

YesNo

Insurance Co. Address:

Street Address

Street Address Line 2

City State

Zip Code

Insurance Co. Name:

Phone #:

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

First Name Middle Name Last Name

Relationship to Patient:

Policy Owner’s Birth date:*

Date

Social Security #:

Employer’s Address:

Street Address

Street Address Line 2

City State

Zip Code

Policy Owner’s Employer:

Secondary Insurance

Dental Coverage?

YesNo

Medical Coverage

YesNo

Orthodontic Coverage?

YesNo

Insurance Co. Address:

Street Address

Street Address Line 2

City State

Zip Code

Insurance Co. Name:

Phone #:

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

First Name Middle Name Last Name

Relationship to Patient:

Policy Owner’s Birth date:*

Date

Social Security #:

Employer’s Address:

Street Address

Street Address Line 2

City State

Zip Code

Policy Owner’s Employer:

Is the child currently in pain? *

YesNo

What is the primary reason for today’s visit?*

Has the child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?

YesNo

Has the child experienced problems with previous dental work?

YesNo

Is the child’s water fluoridated?

YesNo

Is the child taking fluoridated supplements?

YesNo

Does the child brush his / her teeth daily?

YesNo

Floss his / her teeth daily?

YesNo

Previous / Present Dentist:

Date of Last Visit:

Date

Why did you leave your previous dentist?

What did you like most about any dentist you have seen?

Least about?:

Does/did the child have any of the following habits?

Breast Fed

YesNo

Mouth Breather

YesNo

Thumb / Finger Sucking

YesNo

Chewing on Objects

YesNo

Nail Biting

YesNo

Tongue / Cheek Biting

YesNo

Clenching / Grinding Teeth

YesNo

Nursing Bottle Habits

YesNo

Tongue Thrust

YesNo

Lip Sucking / Biting

YesNo

Speech Problems

YesNo

Used Pacifier

YesNo

Child’s Physician:

First Name Middle Name Last Name

Phone #:

Date of Last Visit:

Date

Address

Street Address

Street Address Line 2

City State

Zip Code

Is the child currently under the care of a physician?*

YesNo

Please explain:

Please describe the child’s current physical health:*

GoodFairPoor

Are Immunizations Current?*

YesNo

Anything you would like to discuss with the Doctor in private?

YesNo

Has the child had/experienced any of the following:

Abnormal Bleeding

YesNo

Diabetes

YesNo

Low Blood Pressure

YesNo

AIDS / HIV +

YesNo

Epilepsy

YesNo

Lupus

YesNo

Allergies

YesNo

Handicaps / Disabilities

YesNo

Measles

YesNo

Anemia

YesNo

Hearing Impairment

YesNo

Mitral Valve Prolapse

YesNo

Any Hospital Stays / Operations

YesNo

Heart murmur

YesNo

Mononucleosis

YesNo

Asthma

YesNo

Hemophilia

YesNo

Rheumatic Fever

YesNo

Blood Transfusions

YesNo

Hepatitis

YesNo

Scarlet Fever

YesNo

Cancer

YesNo

High Blood Pressure

YesNo

Sickle Cell Anemia

YesNo

Chicken Pox

YesNo

Hives

YesNo

Skin Rash

YesNo

Congenital Heart Defect

YesNo

Kidney Problems

YesNo

Tonsillitis

YesNo

Convulsions

YesNo

Liver Problems

YesNo

Tuberculosis

YesNo

Please discuss any serious medical problems the child experiences/ed:

My method of payment will be*

Signature of parent or guardian*

Clear

Date

I certify that my child is covered by*

Insurance Co. and I assign directly to Dr.

all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefit. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Signature of parent or guardian*

Clear

Date

The parent or guardian who accompanies the child is responsible for payment at the time of service.

Pediatric Health History Form

Who Is Accompanying The Child Today?

Parent’s Information

Person Responsible for Account

Insurance Information

Dental History

Medical History

Authorizations