Child Health History Form (Updated)

Child Health History Form
Patient Preferred Name
Patient Preferred Pronouns
Patient Full Name
Patient Nickname
Patient Birth Date

MonthDayYear
Date
Sex Assigned at Birth
Patient Age
School (If currently a student)
Grade
Siblings Names & Ages
Patient Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
General Dentist
Office Phone

Area CodePhone Number
Who can we thank for referring you to our office if other than your dentist?
Responsible Party Information

Parent/Guardian information is required if patient not responsible. The office reserves the right to verify the credit status of potential patients seeking payment terms.
Parent 1 OR Responsible Party Name
Marital Status
Address (if different than Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
SSN (Must be provided to verify orthodontic insurance coverage)
Birth Date

MonthDayYear
Date
Employer
Occupation
Years Employed
Parent 2 OR Responsible Party Name
Marital Status
Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
SSN (Must be provided to verify orthodontic insurance coverage)
Birth Date

MonthDayYear
Date
Employer
Occupation
Years Employed
Dental Insurance Information

(Please provide copy of insurance card to office)
Do you have DENTAL Insurance?
Primary Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone

Area CodePhone Number
Name of Employer
Group No.
ID #
Employee Name
Date of Birth

MonthDayYear
Date
Employee Home Address (If different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee relationship to patient
Employee Social Security #
Upload photo of front and back of insurance card

Browse Files

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Do you have Secondary Insurance?
Secondary Insurance Company
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone

Area CodePhone Number
Name of Employer
Group No.
ID #
Employee Name
Date of Birth

MonthDayYear
Date
Employee Home Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee relationship to patient
Employee Social Security #
Upload photo of front and back of insurance card

Browse Files

Cancelof
Emergency Contact
Name of emergency contact (not living in your home)
Phone

Area CodePhone Number
Complete Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Medical History
Is this patient in good health?
Primary Physician
Medical Specialist(s)
Is your child being treated by a physician at this time? (Include reason)
Is your child taking any medications? (If so, please list)
Known allergy or sensitivity to latex?
Known allergy or sensitivity to metals?
List any known allergies:
Is your child up to date on immunizations against childhood diseases?
Please mark yes or no for each of the following, if you answered yes to any question, please provide details in space below question. Does your child have or have a history with any of the following:
Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions
If yes, please explain:
Problems with physical growth or development
If yes, please explain:
Large tonsils (tonsils or adenoids removed), sleep apnea, snoring, or mouth breathing
If yes, please explain:
Excessive gagging
If yes, please explain:
Asthma
If yes, please explain:
RSV
If yes, please explain:
Diabetes, hyperglycemia, or hypoglycemia
If yes, please explain:
Congenital heart defect/disease, murmur, rheumatic fever/heart disease
If yes, please explain:
High blood pressure
If yes, please explain:
Frequent cold/cough, pneumonia
If yes, please explain:
Hepatitis or Liver problems
If yes, please explain:
GERD, reflux, or gastrointestinal issues
If yes, please explain:
Concerns with weight or eating disorders
If yes, please explain:
Bladder or kidney problems
If yes, please explain:
Anemia or prolonged bleeding
If yes, please explain:
Endocrine, thyroid, or pituitary problems
If yes, please explain:
Bone, muscle, or joint problems
If yes, please explain:
Impaired vision, hearing, or speech
If yes, please explain:
Developmental, behavioral, or learning disorders
If yes, please explain:
Epilepsy
If yes, please explain:
ADD/ADHD
If yes, please explain:
Autism spectrum disorder
If yes, please explain:
Fainting, dizziness, or recurrent headaches
If yes, please explain:
Cancer
If yes, please explain:
Mononucleosis (Mono)
If yes, please explain:
Tuberculosis (TB)
If yes, please explain:
Sexually transmitted disease (STD)
If yes, please explain:
HIV/AIDS
If yes, please explain:
Hospitalizations or surgeries
If yes, please explain:
Any other significant medical history:
Has patient reached puberty?
If yes:
If male, has voice changed?
If female, has menstruation started?
Date

MonthDayYear
Date
If female, is patient pregnant?
Dental History
What concerns you most about your teeth and facial appearance?
How would you describe your child’s oral health?
Have there been injuries to the face, mouth or teeth?
Does your child grind or clench their teeth?
Has the patient ever sucked a thumb or finger?
If yes, until what age?
Does the patient have any speech problems?
Have you been informed of any missing or extra teeth?
Has an orthodontist been consulted previously?
Has patient had previous orthodontic treatment?
Have other members of your family had orthodontic treatment?
Has anyone in your family been seen in our office? Name(s)
Does anyone in your family have a similar dental problem?
Has your child had a negative dental experience?
Signature

The above information is correct to the best of my knowledge.
Signature
Date Submitted

MonthDayYear
Date
Should be Empty:

Child Health History Form

Responsible Party Information

Dental Insurance Information

Emergency Contact

Medical History

Dental History

Signature