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

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?

If yes, describe and give the date

Have you ever sucked a thumb or fingers?

Age

Any pain in or near the ears?

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