Child Health/Dental History Form

Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time?

Yes No

If yes, please list:

Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs?

Yes No

If yes, please explain:

Is the child allergic to anything else, such as certain foods?

Yes No

If yes, please explain:

How would you describe the child’s eating habits?

Has the child ever had a serious illness?

Yes No

If yes, when, Please describe:

Has the child ever been hospitalized?

Yes No

Does the child have a history of any other illnesses?

Yes No

If yes, please list:

Has the child ever received a general anesthetic?

Yes No

Does the child have any inherited problems?

Yes No

Does the child have any speech difficulties?

Yes No

Has the child ever had a blood transfusion?

Yes No

Is the child physically, mentally, or emotionally impaired?

Yes No

Does the child experience excessive bleeding when cut?

Yes No

Is the child currently being treated for any illnesses?

Yes No

Is this the child’s first visit to a dentist?

Yes No

If not the first visit, what was the date of the last dentist visit?

Date

Has the child had any problem with dental treatment in the past?

Yes No

Has the child ever had dental radiographs (x-rays) exposed?

Yes No

Has the child ever suffered any injuries to the mouth, head or teeth?

Yes No

Has the child had any problems with the eruption or shedding of teeth?

Yes No

Has the child had any orthodontic treatment?

Yes No

What type of water does your child drink?

City water Well water Bottled water Filtered water

Does the child take fluoride supplements?

Yes No

Is fluoride toothpaste used?

Yes No

How many times are the child’s teeth brushed per day?

When are the teeth brushed?

Does the child suck his/her thumb, fingers or pacifier?

Yes No

At what age did the child stop bottle feeding? Age

Breast feeding? Age

Does child participate in active recreational activities?

Yes No

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

Child Health/Dental History Form

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

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

Child’s History