Health History

Please tell us about your child
Child's Name
Nick Name
Today's Date

MonthDayYear
Date
Sex

MaleFemale
Child's Date of Birth

MonthDayYear
Date
Child's Age
Attends What School:
Is your child adopted?

YesNo
Does the child know?

YesNo
Brother's Names & Ages
Sister's Names & Ages
Dental History
Is this your child's first visit to the dentist?

YesNo
Any unfavorable experiences in another dental office?

YesNo
Are there any specific concerns about the child's mouth or teeth?

YesNo
Please describe further, if necessary:
How many times per day are the child's teeth brushed

0123
Are the child's teeth flossed daily?

YesNo
Does an adult assist with brushing and flossing the child's teeth?

YesNo
Is fluoride toothpaste used?

YesNo
Does the child use any additional fluoride products?

RinseGelWaterTablets or Drops
Has the child had or does the child need orthodontic treatment?

YesNo
Does the child currently nurse?

YesNo
Does the child currently use a bottle or a sippy cup?

YesNo
If yes, does the child have the bottle or sippy cup in bed?

YesNo
Any TMJ pain or symptoms (clicking, popping, limited opening)?

YesNo
Has the child had any injuries to the mouth or face?

YesNo
If yes, please describe:
Does the child have any of the following habits?
Pacifier Use

YesNo
Thumb or Finger Sucking

YesNo
Lip Sucking or Licking

YesNo
Grinds Teeth

YesNo
Bites Nails

YesNo
Tongue Thrust

YesNo
Health History
Has the child ever had a serious illness?

YesNo
If yes, please explain:
Has the child ever been hospitalized?

YesNo
Has the child ever had surgery?

YesNo
Does the child have a syndrome or a genetic disorder?

YesNo
Any congenital birth defects or craniofacial defects?

YesNo
Any physical disabilities?

YesNo
Is the child on the autistic spectrum?

YesNo
Has the child had a history of, or condition related to the following?
Congenital Heart Defect

YesNo
Lung Disease

YesNo
Kidney Disease

YesNo
Liver Disease / Hepatitis

YesNo
Endocrine System

YesNo
Diabetes

YesNo
GI Disease

YesNo
Acid Reflux / GERD

YesNo
Celiac or Irritable Bowel

YesNo
Hemophilia / Bleeding Disorder

YesNo
Blood Disorder

YesNo
Cancer or Tumors

YesNo
Leukemia

YesNo
Developmental Delay

YesNo
Speech Delay

YesNo
Hyperactive / ADD

YesNo
Sensory Integration

YesNo
Vision Impairment

YesNo
Hearing Impairment

YesNo
Seizures or Epilepsy

YesNo
Premature Birth

YesNo
Cerebral Palsy

YesNo
Skin Disorder

YesNo
Please discuss any medical conditions further, if necessary:
Please list allergies (medications, foods, latex):
Please list any medications the child is taking:
Does the child have any of the following breathing issues?
Asthma

YesNo
Environmental Allergies

YesNo
Snoring

YesNo
Enlarged Tonsils/Adenoids

YesNo
Sleep Apnea

YesNo
Trouble Breathing Through

YesNo
Child's Physician
Phone Number:
Please enter a valid phone number.
Parent/Guardian Signature

Clear
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: