Health Status Report Form
Patient Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian/Parent Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Did your home address change?
Yes
No
New Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Did your insurance change?
Yes
No
New Insurance Details
Are the patient's parents legally married (for insurance purposes)?
Yes
No
Has your child seen a physician since his/her last visit?
Yes
No
Please give details about the visit
Has your child's medical history changed since his/her last visit?
Yes
No
Please list the changes
Have there been any injuries to the face, head, neck, mouth, or teeth in the last six months?
Yes
No
Please list the injuries
Is your child up to date with his/her immunizations?
Yes
No
Is your child currently taking any medications?
Yes
No
Please list the medications
Does your child have any allergies (food, seasonal, medications, latex)?
Yes
No
Please list the allergies
Does your home have city water supply or well water?
Yes
No
Does your child take a fluoride vitamin?
Yes
No
Does your child drink water with fluoride?
Yes
No
Is your child being followed by an orthodontist?
Yes
No
Does your child currently have braces or any non-removable dental appliance?
Yes
No
Has your child completed orthodontic treatment?
Yes
No
Has your child had his/her wisdom teeth removed?
Yes
No
Select the one(s) applicable to your child
Sucks thumb/finger
Breathes out of mouth
Thrusts tongue
Bites nails
Breastfeeds
Uses a bottle
Grinds teeth
Problems with speech
Uses a pacifier
Uses a sippy cup
Gag reflex
Are there any other dental or medical related concerns or problems?
Yes
No
Please give details of other dental or medical related concerns or problems.
Is there anything you would like to discuss with the doctor in private?
Yes
No
I, undersigned, agree with the following statements:
I am the parent/guardian of the patient specified above.
I am giving my consent to an exam, cleaning, fluoride treatment and x-rays if deemed necessary.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: