Child Health Questionnaire
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1157595 Forward Dental 1712.qxp:Layout 1
5/21/09
12:54 PM
Page 1
1712 5/09
Child Health Questionnaire
In order to provide a complete dental exam for your child, please answer the following questions as completely as possible.
Date
/
/
Child's Name ___________________________________________________________ Child's Soc. Sec. No. _______________________________
Birthdate
/
/
Age _______ Sex _______ Nickname _______________________________________________________
Father's Name _____________________________________________ Mother's Name __________________________________________________
Favorite Pet or Toy _________________________________________ Pet's Name ______________________________________________________
Is Child Adopted? Yes
No
Legal Guardian's Name ___________________________________________________________________
____________________________________________________________________________________________________________________________
Child's Physician _____________________________________________________________________ Phone _______________________________
Date of Last Physical Examination ___________________________
How is your child's general health? _____________________________________________________________________________________________
Has your child had any serious illness?
Yes
No
If yes, describe: __________________________________________________________________________________________________________
Has your child ever been hospitalized?
Yes
No
For what reason? _________________________________________________________________________________________________________
Is you child receiving any medication at this time?
Yes
No
If yes, describe: __________________________________________________________________________________________________________
Has your child ever had an allergic reaction to the following
Dental Anesthetics
Antibiotics
Food
Drugs
Latex
Please describe: __________________________________________________________________________________________________________
Has your child ever received a blow or injury to his head or teeth? Yes
No
Describe: ________________________________________________________________________________________________________________
Has your child ever been treated with X-ray or radiation therapy?
Yes
No
Has your child ever had any of the following conditions? Please check:
Yes No
Yes No
Yes No
Age ______
Aids or HIV
Age ______
TB (Tuberculosis)
Age ______
Heart Disease
Heart Murmur
Age ______
Bleeding Problems
Age ______
Sickle Cell Anemia
Age ______
Rheumatic Fever
Age ______
Lung Disease
Age ______
Circle Disease or Trait
Diabetes
Age ______
Liver Disease
Age ______
Other (Please describe): ___________________
Scarlet Fever
Age ______
Learning Disability
Age ______
_________________________________________
Kidney Disease
Age ______
Emotional Disturbance
Age ______
_________________________________________
Epilepsy
Age ______
Mental Retardation
Age ______
_________________________________________
Asthma
Age ______
Mononucleosis
Age ______
_________________________________________
Hepatitis
Age ______
Hearing Problems
Age ______
_________________________________________
Does your child have any habits we should know about, such as:
Poor Eating Habits
Thumb Sucking
Pacifier
Bottles
Other ______________________________________
Does your child receive fluoride in: Drinking Water at Home Yes
No
By Prescription
Yes
No
Has your child had any unpleasant dental experiences?
Yes
No
How can we help? ________________________________________________________________________________________________________
Date of last dental examination
/
/
Has your child ever had orthodontic treatment?
Yes
No
When? _____________________________________________________
What is the nature of today's visit? Regular Exam
Emergency
State Problem: _______________________ Other
___________
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my
knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such
information to you. I will notify the doctor of any changes in my health or medication.
I consent to the doctor's exam and necessary diagnostics for treatment including x-rays.
Signature of Parent or Guardian: _______________________________________________________________________________________________
Welcome and thank you for letting us care for your child's smile!
Signature of Doctor/Staff ______________________________________________________________________________________________________
CHILD HEALTH HISTORY
NAME
#
_______________________________________
________________
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