Samuel G. Smith
DMD, MS
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Child Health History
First Name
Middle Name
Last Name
Preferred Name
Birthday
Age
Sex
Patient's Dentist
Referred By
Names of any family members we have seen
Mother
First Name
Last Name
SSN #
Birth Date
Cell Phone
Work Phone
Address
City
State
Zip
Marital Status
Married
Single
Divorced
Widow(er)
Father
First Name
Last Name
SSN #
Birth Date
Cell Phone
Work Phone
Address
City
State
Zip
Marital Status
Married
Single
Divorced
Widow(er)
Person(s) responsible for payment of account
Address
City
State
Zip
Relationship to patient
Primary Insurance
Insurance Carrier
Insurance Phone #
Subscriber Name
Subscriber Id #
Address
City
State
Zip
Group #
Secondary Insurance
Insurance Carrier
Insurance Phone #
Subscriber Name
Subscriber Id #
Address
City
State
Zip
Group #
Medical History
Are you in good health?
Do you have any history of major illness
Please list (give dates)
Check any of the following for which the patient has been treated
Heart Trouble
HIV/Aids
Attention Deficit
Liver Involvement
Mitral Valve Pro
Anemia
Kidney Problems
Hepatitis
Heart Murmer
Epilepsy
Endocrine Problem
Blood Disorders
Rheumatic Fever
Asthma
Prolonged Bleeding
Diabetes
Pneumonia
Tuberculosis
Fainting or Dizziness
Have tonsils and adenoids been removed?
What Age?
List any drugs or medications now being taken and reason
List any allergies or drug sensitivity
Date of onset
Dental History
Date of last dental cleaning
Date of last X-rays
Has the patient had a Panoramic/Panorex X-ray?
Yes
No
Don't know
If yes, when?
Have there been injuries to the face, mouth, or teeth?
Yes
No
If yes, describe and give the date
Have you ever sucked a thumb or fingers?
Yes
No
Age
Any pain in or near the ears?
Yes
No
Signature
Submit