Health History Update

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Child's Birthdate *

Child's Age

Nickname

Child's Home Number

Current Medications

Reason:

Please select Yes or No indicating whether or not your child has any of the following medical problems:

Are your child’s immunizations current?
Yes No

Asthma
Yes No

Abnormal Bleeding/Hemophilia?
Yes No

Please List:

Anemia
Yes No

ADD/ADHD
Yes No

Tourette’s
Yes No

Autism/PDD/Sensory Issues
Yes No

Hospital Stays/Operations
Yes No

Explain:

Cancer
Yes No

Convulsions/Epilepsy
Yes No

Congenital Heart Defect/Heart Murmur
Yes No

Cardiologist's name:

Diabetes- Insulin dependent
Yes No

Type I or Type II:

Hearing Impairment
Yes No

Vision Impaired
Yes No

HIV/AIDS
Yes No

Exposed but negative?
Yes No

Kidney/ Liver Problems
Yes No

Hepatitis
Yes No

Rheumatic Fever/ Scarlet Fever
Yes No

Tuberculosis
Yes No

Handicaps/ Disabilities?
Yes No

Explain:

Is your child having any current dental problems?
Yes No

Explain:

Has your child been seen by another dentist since last seen by us?
Yes No

When:

Who:

Were any x-rays taken?
Yes No

Does child live with:

Any changes in family. ie: divorce, death, military, etc

Mom’s e-mail:

Mom’s work:

Mom’s cell:

Dad's e-mail:

Dad's work:

Dad's cell:

Signature

Dental Insurance

ID#

Policy Holder

Employer

Policy Holders DOB

Signature

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

Relationship to Patient *

Date *