Child Health History Form

Child Health History Form
Welcome! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your child's dental health.
Patient Information
Date

MonthDayYear
Date
SS/HIC/Patient ID #
Birthdate

MonthDayYear
Date
Last Name (Minor/Child)
First Name (Minor/Child)
Middle Initial (Minor/Child)
Sex

MF
Age
Nickname
Hobbies
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
School Name
School Phone
Please enter a valid phone number.Format: (000) 000-0000.
Person financially responsible
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Whom may we thank for referring you?
Insurance
Father's/Guardian's Name
Address (if different from patient's)

Street Address

Street Address Line 2

CityState

Zip Code
Home phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
Work phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
E mail
example@example.com
Employer
Soc. Sec. #
Birthdate

MonthDayYear
Date
Do you have dental insurance coverage for this minor/child (under the father's name)?

YesNo
If yes, Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If yes, Plan Name
If yes, Address
If yes, Group #
If yes, Policy #
Mother's/Guardian's Name
Address (if different from patient's)

Street Address

Street Address Line 2

CityState

Zip Code
Home phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
Work phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
E mail
example@example.com
Employer
Soc. Sec. #
Birthdate

MonthDayYear
Date
Do you have dental insurance coverage for this minor/child (under the mother's name)?

YesNo
If yes, Plan Name
If yes, Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If yes, Address
If yes, Group #
If yes, Policy #
Is your child eligible for treatment under Medical Assistance?

YesNo
If yes, Child's Medical Assistance I.D. #
Dental History
Date of last visit to a dentist

MonthDayYear
Date
For what service?

Rows	Yes	No
Has child complained about dental problems?
Does child brush teeth daily?
Does child use floss every day?
Is fluoride taken in any form?
Any injuries to mouth, teeth, head?
Any unhappy dental experiences?
Any mouth habits - thumbsucking, nail biting, mouth breathing, pacifier, sleeping with bottle, etc?

Medical History
Minor/Child's Physician
City/State
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last physical examination

MonthDayYear
Date
Results

Rows	Yes	No
Is Minor/Child under care of physician now?
Receiving any medication or drugs?
Ever been hospitalized?
Ever had surgery?
Is there excessive bleeding when cut?

Medications
Allergies
Has minor/child had any history with any of the following?

AIDS/HIVAnemiaAsthmaBladder ProblemsCancerCerebral PalsyChicken PoxConvulsionsDiabetesDrug/Alcohol AbuseEpilepsyFaintingHearing ProblemsHeart ProblemsHepatitisKidney DiseaseLiver DiseaseMeaslesMononucleosisMumpsRheumatic FeverSinus ProblemsThyroid DiseaseTuberculosisOther
Emergency Contact

In the event of an emergency, whom should we contact?
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorization
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.
Minor/Child Consent
I am the parent, guardian, or personal representative of Name of Minor/Child and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.
Insurance Assignment and Release
I certify that my dependent(s) is covered by insurance with Name of Insurance Company(ies) and assign directly to Dr. Dr. Name all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my minor/child's health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.
Signature of Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Please print name of Parent, Guardian or Personal Representative
Relationship to Patient
Should be Empty:

Patient Information

Insurance

Dental History

Medical History

Emergency Contact

Authorization