springspediatricdentist.com - Pediatric Medical & Dental History

Pediatric Medical & Dental History
Patient Name
Date of Birth

MonthDayYear
Name of Parent or Guardian
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Whom may we thank for telling you about our office?
Does your child have any current health problems?
What medications is your child currently taking?
Has your child ever had a serious illness, operation, or hospitalization?
If yes, please describe
When?
Has your child ever had, or do they currently have any of the following conditions?

Other
Is your child allergic to, or has he/she reacted adversely to any of the following?

Other
How long since your child's last dental visit?
Has your child ever had an unhappy dental experience?
Is your child having a dental problem now?
If yes, please describe
Has your child ever had any injuries to the teeth, mouth, or head?
If yes, please describe
Check any that apply to your child:
Has your child ever taken a bottle or “sippy cup” at naptime or bedtime?
To the best of my knowledge, the above questions have been answered accurately. I hereby consent to the initial examination, including the taking of diagnostic radiographs (x-rays), photographs, and casts as deemed necessary by Dr. Church.
Signature of Parent/Guardian
Date

MonthDayYear
Should be Empty: