Dental History Form

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School_____________________________
Teacher____________________________
DENTAL HISTORY FORM 2012-2013
PLEASE FILL OUT COMPLETELY
(THIS IS PROTECTED MEDICAL INFORMATION)
Today’s Date:__________________
Child’s Full Name: _____________________________ Preferred Name/Nickname: _____________ Sex: _____
Home Address/ZIP: _______________________________________*Phone Number: ____________________
*Child’s Social Security Number: _______________ Age: _____ Date of Birth: _________ Race: __________
Required Parent/Guardian Information (patient is a minor):
Parent/Guardian’s Name: __________________________ Relationship to child: __________________________
Parent/Guardian Birthday: __________________ *Parent/Guardian’s Social Security Number:____________
Insurance:
Does your child have Medicaid/KCHIP? Y N
If yes, what is the number? ________________________
Does your child have private insurance? Y N
If yes, what is the company? _______________________
Policy Holder’s Name: __________________ Policy Holder’s Social Security Number: _____________
Policy Holder’s Birthday: ________________ Policy #: ___________________________
Company phone number: ________________ Company Address: ______________________________
Medical/Dental:
Is your child taking medicine for any reason? Please list names of all medicines, the reason for taking them, and
how long he/she has been taking them. ___________________________________________________________
___________________________________________________________________________________________
Has your doctor or dentist ever required your child to take antibiotics due to a heart condition before having
dental care? Y N If so, why? ____________________________________________________________
Is your child allergic to latex? ____ Penicillin? _____ Please list any other allergies: _____________________
Does your child drink bottled, city, or well water?
Circle the correct one
Does your child have, or has your child ever had, any of the following?
____ Rheumatic Disease/Heart Problems
____ Asthma
____ Cancer
____ Tuberculosis (TB)
____ Hemophilia or bleeding problems
____ Epilepsy
Please describe any checked problems, or list any other health problems: ________________________________
___________________________________________________________________________________________
Has your child seen a dentist before? Y N
If So When:__________________
During the past six months, has your child had a toothache more than once when chewing? Y N Don’t know
Has your child ever had a traumatic experience at the dentist’s office? Please describe _____________________
_________________________________________
____________
Parent/Guardian Signature
Date

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