drrobertwatson.com - Child Health/Dental History Form

Child Health/Dental History Form
Patient's Name

First NameMiddle NameLast Name
Nickname
Date of Birth

MonthDayYear
Date
Parent's/Guardian's Name
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
MaleFemale
Active TuberculosisPersistent cough greater than a three-week durationCough that produces blood?
lf you check to any of the three items above, please stop filling the form.
AnemiaArthritisAsthmaBladderBleeding disordersBones JointsCancerCerebral PalsyChicken PoxChronic SinusitisDiabetesEar AchesEpilepsyFaintingGrowth ProblemsHearingHeartHepatitisHIV +/AIDSlmmunizationsKidneyLatex allergyLiverMeaslesMononucleosisMumpsPregnancy (teens)Rheumatic feverSeizuresSickle cellThyroidTobacco/Drug UseTuberculosisVenereal DiseaseOther
Please list the name and phone number of the child's physician:
Name of Physician

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Child's History
YesNo
If yes, please list:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
YesNo
If yes, when and please describe:
YesNo
YesNo
If yes, please list:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
lf not the first visit, what was the date of the last dentist visit?

MonthDayYear
Date
YesNo
YesNo
YesNo
YesNo
YesNo
City waterWell waterBottled waterFiltered water
YesNo
YesNo
24. How many times are the child's teeth brushed per day?
When are the teeth brush?
YesNo
26. At what age did the child stop bottle feeding?
Age:
Breast Feeding? Age
YesNo
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form
Parent's/Guardian's Signature

Clear
Date

MonthDayYear
Date
For completion by dentist
Comments
Should be Empty:

Child Health/Dental History Form

Child's History

For completion by dentist