Infant Health History Form

Infant Health History Form

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Patient's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Sex*
Birth Hospital*
Birth Weight*
Present Weight*
Vaginal Birth?*

YesNo
C-Section Birth?*

YesNo
Any Birth Complications?*

YesNo
If yes, please explain
Medical History
Infants are usually given Vitamin K at birth to prevent bleeding in the first 8 weeks of life. Did your child receive the Vitamin K shot?

YesNo
Was your infant premature?*

YesNo
If yes, how many weeks?
Does your infant have heart disease?*

YesNo
If yes, explain?
Has your infant had any surgery?*

YesNo
If yes, explain?
Are you presently breastfeeding?*

YesNo
If no, how long since you stopped breastfeeding?
Bleeding Disorder?*

YesNo
If yes, explain?
Has your infant experienced any of the following? Please check and elaborate as needed
Poor latch at breast or bottle?*

YesNo
If yes, explain
Falls asleep while eating?*

YesNo
If yes, explain
Slides off the nipple when attempting to latch?*

YesNo
If yes, explain
Colic Symptoms*

YesNo
If yes, explain
Reflux Symptoms?*

YesNo
If yes, explain
Clicking or smacking noises when eating?*

YesNo
If yes, explain
Gagging or choking when eating?*

YesNo
If yes, explain
Gassy (toots a lot)/Fussy often?*

YesNo
If yes, explain
Poor Weight Gain?*

YesNo
If yes, explain
Gumming or chewing your nipple when nursing?*

YesNo
If yes, explain
Pacifier falls out easily, or after a few minutes?*

YesNo
If yes, explain
Milk dribbles out of mouth when nursing/bottle?*

YesNo
If yes, explain
Short sleeping requiring feedings every 1-2 hours*

YesNo
If yes, explain
Snoring, noisy breathing or mouth breathing*

YesNo
If yes, explain
Feels like a full time job just to feed baby*

YesNo
If yes, explain
Nose congested often*

YesNo
If yes, explain
Baby is frustrated at the breast or bottle*

YesNo
If yes, explain
Spits up often?*

YesNo
If yes, explain
Is your infant taking any medications?*

YesNo
If yes, explain
Has your infant had a prior surgery to correct the tongue or lip tie?*

YesNo
If yes, explain
How long does it take baby to eat?*
How often does baby eat?*
Do you have any of the following signs or symptoms? Please check and elaborate as needed:
Creased, flattened or blanched nipples*

YesNo
Lipstick shaped nipples*

YesNo
Plugged ducts/engorgement/mastitis*

YesNo
Infected nipples or breasts*

YesNo
Blistered or cut nipples*

YesNo
Nipple thrush*

YesNo
Poor or incomplete breast drainage*

YesNo
Bleeding nipples*

YesNo
Using a nipple shield*

YesNo
One side hurts worse*

YesNo
If yes, right side or left side?
Pain on a scale of 1-10 when first latching*
Pain during nursing (1-10)*
Pediatrician Information
Pediatrician*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Lactation Consultant*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Who referred you to our office?*
Responsible Party Parent/Guardian
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Date of Birth*

MonthDayYear
Date
Parent/Guardian Social Security*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Employer*
Occupation*
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Date of Birth*

MonthDayYear
Date
Parent/Guardian Social Security*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Employer*
Occupation*
Is patient living with both parents?*

YesNo
If no, with whom does the child reside?
Siblings
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Dental Insurance Information
Primary Dental Insurance*
Group No.*
Insurance ID Number*
Policy Holder Name*
Secondary Dental Insurance
Group No.
Insurance ID Number
Policy Holder Name
Consent for Treatment
Signature of Parent/Guardian*
Date*

MonthDayYear
Date
Should be Empty:

Infant Health History Form

Medical History

Has your infant experienced any of the following? Please check and elaborate as needed

Do you have any of the following signs or symptoms? Please check and elaborate as needed:

Pediatrician Information

Responsible Party Parent/Guardian

Siblings

Dental Insurance Information

Consent for Treatment