Patient Medical History (Child) Form
Today's Date
-
Month
-
Day
Year
Date
Patient's Name
First Name
Last Name
Nickname
Patient's Birthdate
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Male
Female
Child's Physician
Office Phone
Please enter a valid phone number.
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Last Exam
-
Month
-
Day
Year
Date
Is your child in good health?
Yes
No
Does your child have a health problem?
Yes
No
If yes, please explain:
Has your child ever been hospitalized, had general anesthesia, or emergency room visit?
Yes
No
Are your child's immunizations up to date?
Yes
No
Does your child have allergies to medications (drugs), medical products (latex) or the environment (dust, mites, pollen, mold)?
Yes
No
List past medications taken by your child:
List daily medications your child is now taking:
Has your child ever had or been treated by a physician for:
Yes
No
Birth Problems
Heart Murmur
Heart Disease
Rheumatic Fever
Anemia
Sickle Cell Anemia
Bleeding/Hemophilia
Blood Transfusion
Hepatitis
AIDS or HIV+
Tuberculosis
Liver Disease
Kidney Disease
Diabetes
Arthritis
Cancer
Cerebral Palsy
Seizures
Asthma
Cleft Lip/Palate
Speech or Hearing Problems
Eye Problems/Contact Lenses
Skin Problems
Tonsil/Adenoid/Sinus Problems
Sleep Problems
Emotional/Behavioral Problems
Radiation Therapy
Growth Problems
Attention Deficit Disorder
If you answered Yes to any of the above, please explain:
Has your child undergone any recent rapid growth?
Yes
No
If yes, by how much?
Parent Information
Father
Height
Weight
Parent Information
Mother
Height
Weight
Sibling Information
Height
Weight
Sibling Information
Height
Weight
Name of Child's School
What grade is the child in at school?
Do you consider your child to be a/an ...
Please Select
Advanced Learner
Progressing Normally
Slow Learner
What is your main concern about your child's dental condition?
Has your child been to a dentist before?
Yes
No
If yes, date of the last visit
-
Month
-
Day
Year
Date
Regular Dentist's Name
Please answer each of the following questions.
Yes
No
Has your child had cavities and/or toothaches?
Are your child's teeth sensitive to temperature or food?
Did you or your child ever get instructions on how to brush their teeth?
Do your child's gums bleed when brushed?
Does your child use fluoride products: rinses, drops, tabs?
Does or has your child had any clicking or pain in the jaw joint?
Does or has your child had any problems opening or closing their mouth?
Has your child ever injured their teeth?
Has your child ever injured their jaw or face?
Does or did your child ever use a pacifier?
Does or did your child suck their fingers or thumbs?
Has your child ever dental X-rays before?
Yes
No
Date of last dental X-rays?
-
Month
-
Day
Year
Date
Will your child be uncooperative?
Yes
No
If yes, please explain:
Has your child experienced any complications following dental treatment?
Yes
No
If yes, please explain:
Has your child inherited any family facial or dental characteristics?
Yes
No
If yes, please explain:
Responsible Party Information
Name
First Name
Last Name
Gender
Please Select
Male
Female
Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient
Employer
Occupation
No. of Years Employed
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
Insured's Name
First Name
Last Name
Insured's Birthdate
-
Month
-
Day
Year
Date
Insured's ID #
*
If this does not apply to you, type "N/A"
Insured's Group #
Insurance Company
Insured's Employer
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have Dual Coverage?
Yes
No
Insured's Name
First Name
Last Name
Insured's Birthdate
-
Month
-
Day
Year
Date
Insured's ID #
Insured's Group #
Insurance Company
Insured's Employer
Insurance Company Phone
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name of Nearest Relative Not Living With You
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Patient
Does your child have any other dental problems we should know about?
Whom may we thank for referring you to our office?
Signature of Person Completing this Form
Relationship to Patient
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