Pediatric Patient History (under 14)

Welcome. In order to assure your child’s safety, comfort and happiness during dental treatment, we need to obtain information from you. Please read carefully and completely answer the questions below. Thank you.

Patient History

First Name

Middle Initials

Last Name

Preferred Name

Nickname (if any):

Date of Birth (MM/DD/YYYY):

Age:

Sex:

Attends what School?

Brothers and Sisters (Names and Age):

Pets (Kind and Name)/Hobbies:

Shows like to watch?

DENTAL HISTORY

Why did you make this appointment?

Is this your child’s first visit to the dentist?
Yes
No
If not, how long since the last dental visit?

Child’s previous dentist name and address:

Approximate date of last dental “x-rays”:

Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
Yes
No
If so, please explain:

Has your child had any injury to the teeth, mouth or jaw?
Yes
No
Does your child have any jaw joint clicking, locking or pain?
Yes
No

CAVITY PREVENTION HISTORY

Does your child receive fluoride daily?
Yes
No
We have fluoride in our water supply.
Yes
No
Child swallows a fluoride supplement daily.
Yes
No
Does your child use a toothpaste containing fluoride?
Yes
No
Does your child use a fluoride mouthwash at home?
Yes
No
Does your child receive a fluoride mouthwash at school?
Yes
No
How often are your child’s teeth brushed?
1x/day
2x/day
3x/day
Is your child familiar with dental floss?
Yes
No
We use floss:
Daily
Occasionally
Never

GROWTH AND DEVELOPMENT HISTORY

Have you ever been advised that your child has a “bite problem?”
Yes
No
Does your child have any oral habits such as thumb, lip or finger sucking, apcifier, nailbiting, clenching or grinding teeth, etc?
Yes
No
Does your child have a speech problem of which you are aware?
Yes
No

MEDICAL HISTORY

Child’s Physician name, address, and phone number:

Does your child have regular medical exams?
Yes
No
Is your child currently under a physician’s care for any reason?
Yes
No
Has your child had any surgery, serious illness, or accident in the past?
Yes
No
If so, please explain:

Has your child had any history of:

Heart trouble/Murmur
Yes
No
Rheumatic Fever
Yes
No
Asthma/Cystic Fibrosis
Yes
No
Diabetes
Yes
No
Kidney or Liver Disease/Hepatitis
Yes
No
Epilepsy or nervous system disorder
Yes
No
Fainting/Seizures
Yes
No
Tuberculosis
Yes
No
Joint Replacement or Implant
Yes
No
Bleeding trouble/Anemia/Hemophilia
Yes
No
Tumor or Cancer
Yes
No
HIV infection or AIDS
Yes
No
Tobacco Use
Yes
No
Eating Disorder
Yes
No
Does your child have any mental, emotional, or physical disabilities?
Yes
No
If so, please explain:

Is your child taking any medications?
Yes
No
If so, please list:

Does your child have any allergies?
Yes
No
Medication

Latex
Yes
No
Metals
Yes
No
Foods

Other

Are your child’s immunizations up to date?
Yes
No

Authorization

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

Permission is hereby granted to the doctor to perform any necessary dental treatments for this child after doctor’s consultation with the parent or presenting adult.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

Signature of patient, parent, or guardian:

Relationship to Patient:


After clicking Submit, please wait a few seconds for the data to be sent.