Health History Form

Parent/Legal Guardian's Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Preferred Name

Gender

Date of Birth

Previous Visit

Contact Information

Parent/Contact 1

Parent Phone 1

Parent Address 1

Parent/Contact 2

Parent Phone 2

Parent Address 2

Preferred Method of Contact

Phone

Text

How Did You Hear About Us?

Mailing Address

City

State

Zip

Parent/Legal Guardian's Name(s)

Pediatrician's Name

Pediatrician's Phone Number

Health History

Does your child have any medical conditions or disabilities?

Yes

If yes, please list

Have you ever been told your child needs antibiotics before a dental visit?

Yes

Has your child ever had heart or cardiac problems?

Yes

Has your child had any surgeries or hospital visits?

Yes

If yes, please list

Does your child take any medications on a daily basis?

Yes

If yes, please list

Does your child have any food or medication allergies?

Yes

If yes, please list

Is your child allergic to latex, pine nuts, or dairy products?

Yes

If yes, please list

Does your child have asthma or reactive airway disease?

Yes

What asthma medications were used last and when?

Please select all the conditions your child currently has, or HAS HAD in the past.

Heart Murmur

Cleft Lip/Palate

Tuberculosis

Hepatitis

Seizures

Hearing/Visually Impaired

Rheumatic Fever

Diabetes

Developmental Delay/CP

Eczema

HIV/AIDS

Ports/Catheters

Anemia/Sickle Cell

Ear Problems

Autism/PDD

Liver/Kidney Disorders

ADD/ADHD

Cancer

None

Does your child have speech problems?

Yes

If yes, who is the speech and language therapist?

Dental History

What is the name of your last dentist?

When was your last visit to the dentist?

At your last visit to the dentist, were x rays taken?

What is the reason for your visit?

Is this your child's first visit to the dentist?

Yes

How do you think your child will do at this visit?

Good

Apprehensive

Uncooperative

Has your child ever had a negative dental experience in the past?

Yes

Has your child had a toothache recently?

Yes

If yes, please explain

Does your child have any of the following habits?

Finger Sucking

Pacifier

Teeth Grinding

None

What type of water does your child drink?

Tap

Fridge

Bottle

Brita

Pur

Other

Has your child ever had any injuries to the jaw, head, mouth, or teeth?

Yes

If yes, please explain

Is there anything else about your child that you think we should know in order to better treat their dental needs?

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I acknowledge that the above information is correct and grant permission to provide my child’s dental and related medical/surgical treatment as deemed necessary, utilizing proper and acceptable methods used in the specialty of pediatric dentistry to complete their treatment.

If there is a change in my child’s health, allergy or medication history, I will inform the dentist & staff immediately prior to any future appointments.

Name of Parent/Legal Guardian

Signature of Parent/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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