Child Dental Health History Form - Northwest Children'S Dentistry Page 2
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2Child’s Name
Dental History
Health History
Is this your child’s first visit to the dentist?
YES
NO
Has the child ever had any of the following conditions?
If not, how long since the last visit to the dentist?
Y N Asthma
Y N Handicaps/ Disabilities
Were any x-rays taken at previous dental visits?
Y N Diabetes
Y N Hearing Impairment
Any injuries to the teeth, face or mouth?
YES
NO
Y N ADD/ ADHD
Y N Skin Disorder
If yes, explain
Y N Heart Problem/ Disease
Y N Hepatitis/ Liver Condition
Y N Convulsions/ Epilepsy
Y N Kidney Condition
Y N Congenital Birth Defects
Y N Rheumatic/ Scarlet Fever
Why did you bring the child to the dentist today?
Y N Hemophilia/ Bleeding Disorder Y N Anemia
Y N Tuberculosis
Y N Sickle Cell Disease/ Traits
Y N Cancer
Y N HIV+/ AIDS
Name of previous dentist
Y N Pregnancy
Y N Drug/ Alcohol Abuse
(if applicable)
Was the previous dental experience positive?
YES
NO
If no, explain
Are the child’s immunizations current?
YES
NO
Any hospitalizations or operations?
YES
NO
If yes, describe
Does the child have any of the following habits?
List all medications the child is currently taking
Thumb/ finger sucking
Uses a bottle
Uses a pacifier
Grinds teeth
List all MEDICATIONS and OTHER SUBSTANCES the child is
allergic to
(i.e. penicillin, latex, peanuts)
Does the child brush his/ her teeth daily?
YES
NO
Please describe any serious medical condition, medical
Does the child floss his/ her teeth daily?
YES
NO
treatment including drugs, pending surgery, recent injuries, or
any other information not yet discussed
Does the child use a mouthwash daily?
YES
NO
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is also my
responsibility to inform this office of any changes in my child’s medical status. I authorize the dentist to release any information
including the diagnosis and the records of any treatment or examination rendered to my child during the period of such dental care
to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist
insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for
services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I also authorize the dental
staff to perform the necessary dental service my child may need.
Signature of Parent or Guardian
Date
The parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have
been approved.
Norman Bunch, DDS, MS & Jennifer Marshall, DDS, MSD
7610 N. La Cholla Blvd - Tucson, AZ 85741
Phone (520) 544-8522
Page 2 of 2
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