PEDIATRIC DENTISTRY HEALTH HISTORY AND PATIENT INFORMATION
Please complete online and email to email@example.com or print and bring to first appointment
Child’s Name (Last / First) Date of Birth Sex: M F Date
Home Address City State Zip
Father’s Name (Last / First) Father’s SSN
Father’s Home Address City State Zip
Father’s Home Phone Work Phone Cell Phone
Father’s Drivers License Number Father’s Date of Birth
Mother’s Name (Last / First) Mother’s SSN
Mother’s Home Address City State Zip
Mother’s Home Phone Work Phone Cell Phone
Mother’s Drivers License Number Mother’s Date of Birth
Is your child covered by a dental insurance plan? Y N Name of Dental Insurance
Medicaid? Y N If Yes, ID Number Your Email Address
In an effort to protect your child’s health information, we willingly release info only to the parents or legal guardians listed above. I understand that
if I want other family members to have access to my child’s information, I will request a disclosure form from the receptionist.
Whom may we thank for referring you?
Other children seen by us? Y N If Yes, Names:
Nearest Relative not living with you Phone
Reason for bringing your child to the dentist
Date of last visit to a dentist For What Service
Has Child Complained about dental problems Y N If Yes,
Any unhappy dental experiences? Y N If Yes,
Any injuries to Mouth, Teeth or Head? Y N If Yes, When?
Any Mouth Habits (Thumb Sucking, Nail Biting, Mouth Breathing, Pacifier, etc)? Y N If Yes,
Does your child brush teeth daily? Y N
Do you assist your child with teeth brushing? Y N How Often?
Child’s attitude to dentistry?
Child’s Physician Address Phone
Date of Last physical examination Results
Is child under care of a physician now? Y N If yes, reason
Is child receiving any medication or drugs? Y N If yes, what?
Has child ever been hospitalized? Y N If yes, reason
Has child ever had surgery? Y N If yes, reason
Is child allergic to penicillin or other drugs? Y N If yes, what?
Are there any other allergies: food, pollen.. Y N If yes, what?
Has child ever had a blood transfusion? Y N If yes, reason
Summary (doctor’s use only) ___________________________________________________________
Has your child ever had any treatment for any of the following? Please check Y or N
Y N Blood-Circulatory Y N Gastrointestinal (stomach) Y N Muscles
Y N Bones Y N Kidney-Bladder Y N Nervous System
Y N Endocrine Glands Y N Heart or Heart Murmur Y N Skin
Y N Eyes, Ears, Nose, Y N Liver Y N Tonsils / Adenoids
Has this child ever been diagnosed as having any of the following conditions? Please check Y or N
Y N AIDS Y N Epilepsy Y N Polio
Y N Anemia Y N Eye Problems Y N Pregnancy
Y N Allergy Y N Excessive Bleeding Y N Psychiatric Problems
Y N Arthritis Y N Fainting Y N Rheumatic Fever
Y N Asthma Y N Hearing Loss Y N Scarlet Fever
Y N Autism Y N Heart Disease Y N Scoliosis
Y N Brain Injury Y N Hemophilia Y N Sickle Cell Anemia
Y N Bronchitis Y N Hepatitis-Type Y N Sinus Problems
Y N Cancer Y N Jaundice Y N Snoring at night
Y N Cerebral Palsy Y N Leukemia Y N Sore Throats (frequent)
Y N Chicken Pox Y N Measles Y N Spina Bifida
Y N Cleft Lip-Palate Y N Mental Retardation Y N Syndrome
Y N Convulsions/Seizures Y N Mumps Y N Tetanus
Y N Developmentally delayed Y N Mouth Breathing Y N Tuberculosis
Y N Diabetes Y N Nutritional Deficiency Y N Veneral Disease
Y N Diptheria Y N Orthopedic Problems Y N Whooping Cough
Y N Drug / Alcohol Abuse Y N Pneumonia Y N Other
Is there anything else that you think we should know about your child?
I certify that I have read and understood the above questions. I will not hold Northeast Children’s Dentistry or any member of the
staff responsible for any errors or omissions I may have made in the completion of this form. I authorize the release of information
to all my insurance companies. I understand that I am responsible or all financial responsibilities.
____________________________________ _________________________________ _____________________
Signature of person completing form Relationship to patient Date