• Child Health & Dental History Form

    CAREFUL COMPLETION OF THIS FORM WILL ASSIST US IN PROVIDING YOUR CHILD WITH THE BEST POSSIBLE DENTAL CARE.

  • Personal Information

  • Gender*
  • Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Health Care Providers

  • Does you child have a family physician?*
  • Does your child have a dentist?*

  • Dental Insurance

  • Does your child have coverage through dental insurance?*
  • Birth date of policy holder
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical Information

  • Is your child being treated by a health care provider for any medical conditions?*
  • Has there been any changes in your child's health in the past year?*
  • Is your child taking any prescriptions, over the counter medications, herbal supplements or vitamins?*
  • Is your child allergic to any medications: i.e. antibiotics or other drugs?*
  • Has your child ever had a peculiar or adverse reaction to any medicines or injections?*
  • Is your child allergic to anything else? (i.e. foods/chemicals/environmental)*
  • Has your child ever needed to take antibiotics before his/her dental appointments?*
  • Does your child have or ever had a replacement or repair of a heart valve or infection of the heart or a heart condition from birth?*
  • Has your child ever been hospitalized?*
  • Has your child had a history of, or a condition related to, any of the following. Please check all those that apply.*
  • Has your child had any history of any other illnesses?*
  • Does your child have any conditions or therapies that could affect his/her immune system? ie: Aids/HIV. Chemotherapy or radiation treatments?*
  • Does your child have any inherited problems?*
  • Does your child have any speech or hearing difficulties?*
  • Does your child experience excessive bleeding when cut?*

  • Dental History

  • Is this your child's first visit to a dental health care provider?*
  • If not the first visit, what was the date of their last dental visit?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has your child ever had any dental x-rays?*
  • Has your child had any problems with dental treatments in the past?*
  • How do you think your child will react to this dental visit?*
  • Has your child ever suffered any injuries to their head, mouth or teeth?*
  • Has your child had any issues with eruption or shedding of teeth?*
  • Has your child ever had any cavities?*
  • Has your child had any orthodontic treatment?*
  • Does your child take fluoride supplements?*
  • Is fluoride toothpaste used?*
  • Do you prefer a natural approach for your child's dental care? e.g. no fluorides, antibacterial products etc.*
  • Does the child suck on his/her thumb, fingers or pacifier?*

  • Consent for Treatment & Privacy Policy

     I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history on behalf of my child. I have not knowlingly omitted any information. I have had the opportunity to ask questions and receive answers regarding the medical-dental history. 

    Should there be any change in either my child's health status or any other information I have provided, I will advise the dental hygienist.

    I authorize the provider, (dental hygienist) to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment for my child.  I understand this action will give my consent verbally.

    I understand the information provided from or to my child's medical doctor, dentist or another health care provider may be necessary.

    I give permission to the dental hygienist to correspond through a phone call, text or email communication, if necessary, with me or my child's health care provider. I am aware, although necessay precautions are in place to protect my child's personal, medical and dental information, communication through email, phone or text may not be entirely secure. 

    I have had the opportunity to ask questions and have been advised of the privacy policy of the office and that my child's personal information will be collected, used and disclosed within the guidelines of the policy

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: