Please enable JavaScript in your browser to complete this form.CHILD HEALTH HISTORY Child's NameBirth DatePhoneIs the child under the care of a Physician?YesNoWhy?What medications is the child currently taking?Is the child allergic to any medications or substances?AspirinCodeinePenicillinLatexSulfaJewelry/MetalsOtherHas the child been instructed to pre-medicate with antibiotics before receiving dental care?YesNoHas the child experienced any of the following?Rheumatic FeverHeart MurmurMitral Valva ProlapseAny Heart ProblemAsthmaAIDS/HIVDiabetesCancer/TumorsJaw Joint ProblemsChemotherapyEpilepsy/SeizuresFainting/DizzinessHemophiliaHepatitisPlease list any medical condition not listed above.CHILD DENTAL HISTORY Reason for today’s visit?Describe any dental problems that the child may have.When was the child's last dental check-up?When was a panoramic x-ray taken?Are you concerned the child may need orthodontics?YesNoHas the child seen an orthodontistYesNoHow would you rate the child’s tooth brushing?GoodFairPoorVery PoorHow often does the child brush?Does the child use a power tooth brush?YesNoPlease check any habits the child may have.Drinks soda dailyEats sweets between mealsChews gum / eats candyUses breath mintsSucks thumb or pacifierGoes to bed without brushingAre there any other concerns?Does the child play sports?YesNoDoes the child wear a protective mouth guard?YesNoType of water the child drinks?City WaterWell WaterBottled water w/ fluorideBottled water w/o fluorideAre fluoride supplements taken?YesNoIs there any additional information that we should know about the child? By submitting this form you understand that the information you have given is correct. You authorize treatment of required dental services and release of information for medical consultation and referral, as well as insurance submission. You also understand that it is your responsibility to inform this office of any changes the child’s medical status.Submit
