drrobertwatson.com - Child Health/Dental History Form

Child Health/Dental History Form
Patient's Name

First NameMiddle NameLast Name
Nickname
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's/Guardian's Name
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Sex
Have you (the parent/guardian) or the patient had any of the following diseases or problems?
lf you check to any of the three items above, please stop filling the form.
Has the child had any history of, or conditions related to, any of the following:

Other
Please list the name and phone number of the child's physician:
Name of Physician

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's History
1. Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time?
If yes, please list:
2. ls the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs?
If yes, please explain:
3. ls the child allergic to anything else, such as certain foods?
If yes, please explain:
4. How would you describe the child's eating habits?
5. Has the child ever had a serious illness?
If yes, when and please describe:
6. Has the child ever been hospitalized?
7. Does the child have a history of any other illnesses?
If yes, please list:
8. Has the child ever received a general anesthetic?
9. Does the child have any inherited problems?
10. Does the child have any speech difficulties?
11. Has the child ever had a blood transfusion?
12. Is the child physically, mentally, or emotionally impaired?
13. Does the child experience excessive bleeding when cut?
14. Is the child currently being treated for any illnesses?
15. ls this the child's first visit to a dentist?
lf not the first visit, what was the date of the last dentist visit?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
16. Has the child had any problem with dental treatment in the past?
17. Has the child ever had dental radiographs (x-rays) exposed?
18. Has the child ever suffered any injuries any injuries to the head, mouth or teeth?
19. Has the child had any problems with the eruption or shedding of teeth?
20. Has the child had any orthodontic treatment?
21. What type of water does your child drink?
22. Does the child take fluoride supplements?
23. Is fluoride toothpaste used?
24. How many times are the child's teeth brushed per day?
When are the teeth brush?
25. Does the child suck his/her thumb, fingers or pacifier?
26. At what age did the child stop bottle feeding?
Age:
Breast Feeding? Age
27. Does the child participate in active recreational activities?
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form
Parent's/Guardian's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For completion by dentist
Comments
Should be Empty:

Child Health/Dental History Form

Child's History

For completion by dentist