Health History Form | Gold River Pediatric Dentistry

Health History Form

This form is available in both English and Spanish. To change languages, please click the toggle in the top right hand corner of this form. Para ver la versión en español de este formulario, cambie elidioma utilizando el interruptor en la esquina superior derecha.

Phone Numbers*

Phone Numbers*

Phone Numbers*

No insurance
Policy Holder's Name

First NameMiddle NameLast Name
Relationship
Policy Holder's Birthdate

MonthDayYear
Social Security Number
Policy Holder's Employer
Insurance Company Name
Group Number (Plan, Local or Policy #)
Insurance Comany Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you have secondary insurance, does your child reside with you?

50% of the time100% of the time
Policy Holder's Name

First NameMiddle NameLast Name
Relationship
Policy Holder's Birthdate

MonthDayYear
Social Security Number
Policy Holder's Employer
Insurance Company Name
Group Number (Plan, Local or Policy #)
Insurance Comany Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth/Development*

Neurological/Physiological*

Rows	Yes	No
Autism spectrum disorder
Sensory processing disorder
Impaired vision, hearing or speech
Developmental delay or intellectual disability
Cerebral palsy or brain injury
Epilepsy or seizures
Vagal Nerve stimulator
Frequent headaches or fainting
Hydrocephaly or shunt (VP, VA, VV)
ADD/ADHD
Behavioral or psychiatric problems
Depression
Anxiety

Heart*

Blood*

Rows	Yes	No
Hemophilia or other bleeding disorder
Anemia
Sickle cell trait/disease
Blood transfunction
Frequent nosebleeds

Head & Neck/Sleep*

Respiratory*

Musculoskeletal*

Rows	Yes	No
Artificial joint
Arthritis
Limited use of arms/legs
Scoliosis/Lordosis/Kyphosis

Infectious Disease*

Digestive*

Cancer History*

Other:*

Rows	Yes	No
Bladder or kidney problems
Eczema or other skin problems

Endocrine*

Rows	Yes	No
Diabetes
Thyroid or pituitary problems
Precocious puberty or other hormonal problems

Family History*

Rows	Yes	No
Malignant hypertermia (MH)

Females Only*

Rows	Yes	No
Is there any chance you could be pregnant?

Allergy to any of the following*

LatexNickel/silverDental anestheticSedativesSoyEgg yolkTree nutsMilk proteinNone
Allergies to any foods or medications?*

YesNo
List
Is your child taking any medications?*

YesNo
List
Are your child's immunizations up-to-date?*

YesNo
Comment
if needed
Has your child been ever treated in an emergency room?*

YesNo
List
Has your child ever been hospitalized?*

YesNo
List
Has your child ever had surgery, including dental surgery?*

YesNo
List
Is there anything on your child's medical dental or family history that the dentist should be aware of?*

YesNo
List

I authorize the following dental procedures for my child - a cleaning, x-rays and/or fluoride application, if advised.
Initial*
Signature*
Relationship to child*
Legal guardian*

YesNo
Date*

MonthDayYear
Dentist's notes
Dentist Signature
Date*

MonthDayYear
Should be Empty: