Dr. Cruz Pediatric Health History

Tell Us About Your Child:

Child’s Name:

First NameMiddle NameLast Name

Child’s Birth date:

Date

Child’s Age:

Child’s Home Phone #:

Format: (000) 000-0000.

Social Security #:

Nickname:

School:

Grade:

Child’s Home Address:

Street Address

Street Address Line 2

CityState

Zip Code

Name:

First NameMiddle NameLast Name

Relationship:

Do you have legal custody of this child?

Is the child adopted?

Is the child in a foster home?

Whom may we Thank for referring you?

Other siblings seen by us:

Neighbor or Relative not living with you

His/ Her Name:

First NameMiddle NameLast Name

Relationship:

Address

Street Address

Street Address Line 2

CityState

Zip Code

Work Phone #:

Format: (000) 000-0000.

Home Phone #:

Format: (000) 000-0000.

Parent’s Marital Status:

Mother:

Birth date

Date

Home Phone #:

Format: (000) 000-0000.

Work Phone #:

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState

Zip Code

Name

First NameMiddle NameLast Name

Social Security #:

Driver’s License #:

Employer:

Length of Employment:

Father:

Birth date

Date

Home Phone #:

Format: (000) 000-0000.

Work Phone #:

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState

Zip Code

Name

First NameMiddle NameLast Name

Social Security #:

Driver’s License #:

Employer:

Length of Employment:

Name

First NameMiddle NameLast Name

Relationship:

Address

Street Address

Street Address Line 2

CityState

Zip Code

Work Phone #:

Format: (000) 000-0000.

Home Phone #:

Format: (000) 000-0000.

Driver’s License #:

Social Security #:

Employer:

Who is responsible for making appointments?

Name

First NameMiddle NameLast Name

Work Phone #:

Format: (000) 000-0000.

Home Phone #:

Format: (000) 000-0000.

Best Time to call:

Primary Insurance

Dental Coverage?

Medical Coverage

Orthodontic Coverage?

Insurance Co. Address:

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Co. Name:

Phone #:

Format: (000) 000-0000.

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

First NameMiddle NameLast Name

Relationship to Patient:

Policy Owner’s Birth date:

Date

Social Security #:

Employer’s Address:

Street Address

Street Address Line 2

CityState

Zip Code

Policy Owner’s Employer:

Secondary Insurance

Dental Coverage?

Medical Coverage

Orthodontic Coverage?

Insurance Co. Address:

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Co. Name:

Phone #:

Format: (000) 000-0000.

Group # (Plan, Local or Policy #):

Policy Owner’s Name:

First NameMiddle NameLast Name

Relationship to Patient:

Policy Owner’s Birth date:

Date

Social Security #:

Employer’s Address:

Street Address

Street Address Line 2

CityState

Zip Code

Policy Owner’s Employer:

Is the child currently in pain?

What is the primary reason for today’s visit?

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

Has the child experienced problems with previous dental work?

Is the child’s water fluoridated?

Is the child taking fluoridated supplements?

Does the child brush his / her teeth daily?

Floss his / her teeth daily?

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

Mouth Breather

Thumb / Finger Sucking

Chewing on Objects

Nail Biting

Tongue / Cheek Biting

Clenching / Grinding Teeth

Nursing Bottle Habits

Tongue Thrust

Lip Sucking / Biting

Speech Problems

Used Pacifier

Child’s Physician:

First NameMiddle NameLast Name

Phone #:

Format: (000) 000-0000.

Date of Last Visit:

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Is the child currently under the care of a physician?

Please explain:

Please describe the child’s current physical health:

Are Immunizations Current?

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

Has the child had/experienced any of the following:

Abnormal Bleeding

Diabetes

Low Blood Pressure

AIDS / HIV +

Epilepsy

Lupus

Allergies

Handicaps / Disabilities

Measles

Anemia

Hearing Impairment

Mitral Valve Prolapse

Any Hospital Stays / Operations

Heart murmur

Mononucleosis

Asthma

Hemophilia

Rheumatic Fever

Blood Transfusions

Hepatitis

Scarlet Fever

Cancer

High Blood Pressure

Sickle Cell Anemia

Chicken Pox

Hives

Skin Rash

Congenital Heart Defect

Kidney Problems

Tonsillitis

Convulsions

Liver Problems

Tuberculosis

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

My method of payment will be

Signature of parent or guardian

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

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