Patient Dentistry History Form
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1
2P
I
ATIENT
NFORMATION
Date: ________________
Patient Name: _____________________________________________ Nick Name: ___________________________
Birthday: ____________________________ Age: _________ Grade: ______________ Sex:
Male
Female
School: __________________________________ Names and ages of siblings: ______________________________
Home Phone: ___________________ Cell Phone: ___________________ Email: ___________________________
Home Address: ___________________________________________________________________________________
Street
City/State
Zip Code
Who has legal custody of the patient? _________________________________________________________________
Your relationship to the patient:
Mother
Father
Guardian
Other: __________________________
Your name: ________________________ Your SSN: ____________________ Your Date of Birth: ______________
Whom may we thank for referring you to us? ___________________________________________________________
What is the reason for your child’s dental visit today? ____________________________________________________
E
C
MERGENCY
ONTACT
In the event of an emergency, whom should we contact?
Name: _________________________________ Relationship: ___________________ Phone: ___________________
Name: _________________________________ Relationship: ___________________ Phone: ___________________
H
H
EALTH
ISTORY
Yes
No
Is your child in good health?
Date of last physical exam: ___________________________
Name of child’s physician: ______________________________________ Phone: _________________________
Yes
No
Has your child ever had a health problem?
Yes
No
Has your child ever been hospitalized or had surgery?
Reason(s): __________________________________________________________________________________
Date(s): ____________________________________________________________________________________
Yes
No
Does your child have excessive bleeding when cut?
Yes
No
Is your child allergic to anything?
If so please list: ______________________________________________________________________________
Yes
No
Is your child currently taking any medications?
Please list medication(s) and reason(s): ____________________________________________________________
Yes
No
Were there any health problems at birth?
If so please list: ______________________________________________________________________________
Please check if your child has been treated for any of the following:
Yes
No Heart disease
Yes
No Bleeding/transfusions
Yes
No Asthma
Yes
No Blood dyscrasias
Yes
No Tuberculosis
Yes
No Liver/GI disease
Yes
No Rheumatic fever
Yes
No Anemia
Yes
No AIDS/HIV
Yes
No Fainting
Yes
No Kidney disease
Yes
No Cleft lip/palate
Yes
No Diabetes
Yes
No Mental Delays
Yes
No Bladder Diff
Yes
No Speech/hearing
Yes
No Seizures/Epilepsy
Yes
No Hepatitis
Yes
No Physical Delays
Yes
No Chicken Pox
Yes
No Cerebral Palsy
Yes
No Congenital birth defects
Yes
No Thyroid Disease
Yes
No Personality/Social
Yes
No Measles/Mumps
Yes
No Cancer/Tumors
Yes
No Recurrent headaches
Yes
No Drug/Alcohol Abuse
Yes
No Frequent Infections
Yes
No Other: ___________
Please elaborate on any checked items:
__________________________________________________________________________
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Parent category: Medical