Child Health History Form

Child 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.
About Your Child
Child's Full Name*

First NameLast Name
Sex
Age*
Birth Date*

MonthDayYear
Date
Reason for Visit*
Referred To This Office By:
Full Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Dental History
Is this your child’s first dental visit?*

YesNo
Previous Dentist*
Previous Dentist City*
Date of last dental visit*

MonthDayYear
Date
Date of last X-rays*

MonthDayYear
Date
Any injuries to the teeth or jaws?*

YesNo
If yes, when
Does Your Child Receive:*

Fluoride in vitaminsFluoridated waterGummy vitaminsFluoride tabs/dropsNone
Has your child experienced any unfavorable reaction from previous medical or dental care?*

YesNo
If yes, explain
How do you think your child will act towards the dentist?*
Medical History
Child's Physician/Pediatrician's Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is your child presently under the care of a specialist for any medical reason?*

YesNo
If yes, what?*
Specialist's Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have a history of health problems?*

YesNo
If yes, what?
Are antibiotics necessary for dental work because of a heart murmur, heart defect, prosthesis, shunt or other medical reason?*

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

YesNo
If yes, explain?
Has your child had a history of taking frequent medications?*

YesNo
If yes, explain?
Has your child been hospitalized or had surgery?*

YesNo
If yes, explain?
Is your child allergic to any drugs?*

YesNo
If yes, explain?
Is your child allergic to any foods?*

YesNo
If yes, explain?
Is your child allergic to any medications or dyes?*

YesNo
If yes, explain?
Is your child allergic to any environmental pollutants?*

YesNo
If yes, explain?
Is your child allergic to any latex, metals, or acrylics?*

YesNo
If yes, explain?
Has any family member, including your child had a problem with general anesthetic?*

YesNo
If yes, explain?
Has your child ever been diagnosed as having any of the following conditions? Check Yes or No.
ADD/ADHD?*

YesNo
AIDS/HIV?*

YesNo
Anemia?*

YesNo
Arthritis?*

YesNo
Asthma?*

YesNo
Autism?*

YesNo
Birth Defects?*

YesNo
Bladder Conditions?*

YesNo
Blood Disease?*

YesNo
Blood Transfusions?*

YesNo
Bone or Joint Problems?*

YesNo
Brain Injury?*

YesNo
Bruising Easily?*

YesNo
Cancer or Malignancies?*

YesNo
Cerebral palsy?*

YesNo
Chemotherapy/Radiation?*

YesNo
Child Abuse?*

YesNo
Chronic Adenoid/Tonsil Infections?*

YesNo
Chronic Ear Infections?*

YesNo
Cleft Lip/Palate?*

YesNo
Congenital Heart Lesion?*

YesNo
Convulsions/Seizures?*

YesNo
Developmentally Delayed?*

YesNo
Diabetes?*

YesNo
Drug Addiction?*

YesNo
Ear Stuffiness, Itching, or Noises?*

YesNo
Emotional Disturbance?*

YesNo
Epilepsy?*

YesNo
Eye Problems?*

YesNo
Excessive Bleeding Problem?*

YesNo
Excessive Gagging?*

YesNo
Fainting or Dizziness?*

YesNo
Fever Blisters?*

YesNo
Growth/Developmental Problems?*

YesNo
Heart Surgery?*

YesNo
Headaches?*

YesNo
Hearing/Speech Impairments?*

YesNo
Heart Murmur/Defects?*

YesNo
Hemophilia?*

YesNo
Hepatitis/Liver Disease?*

YesNo
High Blood Pressure?*

YesNo
Kidney disease?*

YesNo
Leukemia?*

YesNo
Mental Disability?*

YesNo
Mouth Sores?*

YesNo
Nutritional Deficiency?*

YesNo
Orthopedic Problems?*

YesNo
Pain in Jaw Joints?*

YesNo
Premature Birth?*

YesNo
Psychiatric Care?*

YesNo
Rheumatic Fever?*

YesNo
Scoliosis?*

YesNo
Sickle Cell Anemia?*

YesNo
Tuberculosis?*

YesNo
Syndrome?*

YesNo
If yes, explain?
Other?*

YesNo
If yes, explain?
Do you wish to talk to the doctor privately about a special concern?*
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:

Child Health History Form

About Your Child

Referred To This Office By:

Dental History

Medical History

Has your child ever been diagnosed as having any of the following conditions? Check Yes or No.

Responsible Party Parent/Guardian

Siblings

Dental Insurance Information

Consent for Treatment