Medical & Dental Health History Form

1. Tell Us About Your Child

Date*

Child's Name*

Nickname

Child's Age*

Birthday*

Sex

Male
Female

SS#

School

Grade

Name of previous dentist/location (if applicable)

Child's Home Address

Address City

Address Zip

Child's Home Phone #

Do the parents and child all live together?

Yes
No

(Separated Parents: The parent who brings the child is responsible for the account.)

What is the primary reason for today's visit (e.g. pain, checkup, etc.)?

Name of pediatrician

Pediatrician Contact #

2. General Information

Name of person accompanying the child today

Relation

Other Siblings?

Name of relative or friend not living with you

Phone #

Address

3. Parent's Information

Marital Status

Married
Single
Divorced
Separated
Widowed
Remarried
Partnered

Person One

Father
Stepfather
Guardian

Name

DOB

Home #

Cell #

SS#

DL#

Email

Occupation

Employer

Work #

Person Two

Mother
Stepmother
Guardian

Name

DOB

Home #

Cell #

SS#

DL#

Email

Occupation

Employer

Work #

4. Dental History

Is your child currently experiencing discomfort?

Yes
No

Is this your child's first time seeing a dentist?

Yes
No

If no, please describe your child's previous experience:

Previous Dentist

Date of last visit

Films taken?

Yes
No

Does your child brush his/her teeth?

Yes
No

How often?

With help?

Does your child floss?

Yes
No

How often?

With help?

Did/does your child go to bed with a bottle?

Yes
No

Contents:

Does you child clench or grind his/her teeth?

Yes
No

Does you child have any habits?

Yes
No

Is/was your child breast fed?

Yes
No

Check all that apply:

Nail biting
Thumb sucking
Mouth breathing
Pacifier
Cheek biting
Tongue thrusting

Is your child taking fluoride supplements?

Yes
No

Is your child's water fluoridated?

Yes
No

Water Type

City
Well
Bottled
Other

If other, please explain

Has your child ever seen an orthodontist?

Yes
No

If yes, who?

Has your child ever experienced trauma to the lips, chin, teeth, or gums?

Yes
No

If yes, when?

Please explain

Has your child ever had any adverse reaction(s) to any dental procedures?

Yes
No

If yes, please explain

5. Medical History

How would you rate your child's current physical health?

Poor
Fair
Good

Are immunizations current?

Yes
No

Please list any medications and doses the child is taking.

If none, please check here:

None

Please list any medications your child has a known allergy to.

Has your child ever been hospitalized?

Yes
No

If so, when?

Please explain

Has your child ever had surgery?

Yes
No

If so, when?

Please explain

Has your child ever had a history of the following? (Check all that apply)

If none, check here:

NONE

Allergies

Environmental
Latex
Nickel
Tree Nuts

Allergies

Dyes/Flavorings

List Dyes/Flavorings

Allergies

Other

If other:

Health Issues

If premature, how many weeks?

Please describe any additional issues here:

6. Insurance Information

Primary Insurance

Is insurance provided through an employer?

Yes
No

If yes, please list:

Insurance Company Name

Phone #

Subscriber #

Group #

Insured Co's Address

Insured's Name

Secondary Insurance

Is insurance provided through an employer?

Yes
No

If yes, please list:

Insurance Company Name

Phone #

Subscriber #

Group #

Insured Co's Address

Insured's Name

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform Grandville Pediatric Dentistry of any changes to my child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signed*

Date*

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Email

This field is for validation purposes and should be left unchanged.

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Medical & Dental Health History Form

1. Tell Us About Your Child

2. General Information

3. Parent's Information

4. Dental History

5. Medical History

Has your child ever had a history of the following? (Check all that apply)

6. Insurance Information

Primary Insurance

Secondary Insurance

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Menu

Medical & Dental Health History Form

1. Tell Us About Your Child

2. General Information

3. Parent's Information

4. Dental History

5. Medical History

Has your child ever had a history of the following? (Check all that apply)

6. Insurance Information

Primary Insurance

Secondary Insurance

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