Pediatric Dentistry Of North Texas Patient Information And Health History Form

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Office Use Only
Chart #___________________
Health Alerts
Yes
No
PEDIATRIC DENTISTRY
Of North Texas
PATIENT INFORMATION AND HEALTH HISTORY FORM
Child’s Name: ____________________________________ Nickname: ____________________ Date of Birth: __________________
Address: __________________________________________________ City: ______________________ State: _______ Zip: _______
Home Phone: ___________________________ SS#:________-________-___________ Age: _______ Sex: Male Female (Circle)
Mother/Legal Guardian: ____________________________________________ Relation to Patient: ___________________________
Employer: ____________________________________________ Work #:_______________________ Cell: _____________________
Email: ____________________________________________ Date of Birth: _________________ SS#:________-______-___________
Father/Legal Guardian: _____________________________________________ Relation to Patient: ___________________________
Employer: ____________________________________________ Work #:______________________ Cell: ______________________
Email: ____________________________________________ Date of Birth: _________________ SS#:________-______-___________
Person responsible for the account: ______________________________________
What other children in your family have we seen? ___________________________________________________________________
Who referred you to our office? _________________________________________________________________________________
MEDICAL HISTORY
Child’s Physician/Pediatrician: ________________________________________________ Phone: ____________________________
 Yes  No Is your child in good health? Date of last physical exam _________________________________________________
 Yes  No Has your child ever had a health problem? ___________________________________________________________
 Yes  No Is your child allergic to anything? If yes, what? ________________________________________________________
 Yes  No Are your child’s immunizations/vaccines up to date? If not, please explain: _________________________________
 Yes  No Has your child had any surgeries/hospitalizations? If yes, explain _________________________________________
 Yes  No Is your child currently taking any medications? Please give medications, dose, and reason: _____________________
____________________________________________________________________________________________________________
Please check if your child has been treated for any of the following:
 AIDS
 ADHD/ADD
 Anemia
 Asthma/breathing
 Autism
 Blood dyscrasias
 Cancer/Tumors
 Cerebral Palsy
 Cleft lip/palate
 Congenital birth defects  Diabetes
 Endocrine/growth
 Eyesight
 Food Allergies
 Frequent Infections
 Headaches
 Heart Disease
 Heart Murmur
 Hepatitis
 Kidney Disease
 Latex Allergy
 Liver/GI Disease
 Mental delays
 Personality/social
 Pregnant
 Rheumatic fever
 Seasonal Allergies
 Seizures
 Shunt
 Sickle Cell Disease
 Snoring
 Speech/hearing
 Spina bifida
 Syndrome __________
 Tonsil/adenoid
 Tuberculous
 Other ________________________________________________________
Has any member of your child’s family had any of the above? If yes, please explain ________________________________________
____________________________________________________________________________________________________________
Staff | [SCHOOL]

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