Health Information Form

Patient's Name*

First Last

Date of Birth*

Last Dental Exam (including school-based programs)

Where was this Exam?

Patient's Physician

Physician's Phone

Physician's Address

Street Address Address Line 2 City State ZIP Code

When Was Patient's Last Medical Examination?

Has Your Child Ever Been Hospitalized?

When and for what reason?

Is Your Child On Any Medication?

What and for what reason?

Is Your Child Allergic To Any Medication?

What Medications?

Any Known Allergies or Reactions to Dental Anesthetics?

Please Explain or List

Any Other Allergies - Latex, Food, Environmental?

Please Explain or List

Please Indicate If Your Child Has/Had A History or Any Difficulty With Any of the Following:

Anemia

Epilepsy

Muscle or Bone Disease

Asthma

Fainting

Rheumatic Fever

Birth Defect

Hearing

Scarlet Fever

Bleeding Disorders

Heart Trouble/Murmur

Sight

Blood Transfusion

Hepatitis

Speech Problems

Cerebral Palsy

HIV/AIDS

Thyroid

Convulsions

Immune System

Tuberculosis

Diabetes

Kidney Disease

Nervous Disorders

Depression

Artificial Prosthesis

Liver Disease

Any other social, developmental or health diagnosis or concern(s) not listed above that you feel we should be aware of? (i.e. autism, sensory issues, abuse, etc.)

Does or Did your Child Suck their Thumb or Fingers?

Does or Did your Child have a Pacifier Habit?

Was, or Is your Child Breast Fed or Bottle Fed?

Is there any additional information that may help us in caring for your child or any specific concerns that you have regarding your child's dental health?

E Signature of Parent or Guardian*

First Last

I agree that the information provided is correct to the best of my knowledge and I give my permission for treatment in this office. We reserve the right to charge for or limit appointment availability for any appointment missed without adequate advance notice given.

Date*

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Please Indicate If Your Child Has/Had A History or Any Difficulty With Any of the Following:

Health Information Form

Please Indicate If Your Child Has/Had A History or Any Difficulty With Any of the Following:

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