Child Health/Dental History Form

  • Child Health/Dental History Form

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Sex

  • Have you (the parent/guardian) or the patient had any of the following diseases or problems?

  • Active Tuberculosis
  • Persistent cough greater than a three-week duration
  • Cough that produces blood?

  • If you answer yes to any of the three items above, please stop and return this form to the receptionist.

  • Has the child had any history of, or conditions related to, any of the following:

  • Please list the name and phone number of the child’s physician:

  • Phone
     - -

  • Child’s History

  • Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time?
  • Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs?
  • Is the child allergic to anything else, such as certain foods?
  • Has the child ever had a serious illness?
  • Has the child ever been hospitalized?
  • Does the child have a history of any other illnesses?
  • Has the child ever received a general anesthetic?
  • Does the child have any inherited problems?
  • Does the child have any speech difficulties?
  • Has the child ever had a blood transfusion?
  • Is the child physically, mentally, or emotionally impaired?
  • Does the child experience excessive bleeding when cut?
  • Is the child currently being treated for any illnesses?
  • Is this the child’s first visit to a dentist?
  • If not the first visit, what was the date of the last dentist visit?
     - -
  • Has the child had any problem with dental treatment in the past?
  • Has the child ever had dental radiographs (x-rays) exposed?
  • Has the child ever suffered any injuries to the mouth, head or teeth?
  • Has the child had any problems with the eruption or shedding of teeth?
  • Has the child had any orthodontic treatment?
  • What type of water does your child drink?
  • Does the child take fluoride supplements?
  • Is fluoride toothpaste used?
  • Does the child suck his/her thumb, fingers or pacifier?
  • Does child participate in active recreational activities?

  • 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.

  • Date
     - -
  • Should be Empty: