Child Patient Form

Patient Information and Health History

Child’s Information and Health Information

Initial Exam

Childs Information

Child’s Name
Date of Birth
Child’s Address
Child’s Phone
Hobbies, Sports and Interests
In Case of Emergency Contact 
Residence Phone
Residence Address
Cell/Other Phone
Email Address
Business Phone
Dental Insurance Plan (if any)
Dental Insurance ID#
In Case of Emergency Contact
Referred By

Dental History

Chief Oral Complaint
Date of Last Oral Exam
Any Previous Major Dental Treatment

Does the child have, has had or use any of the following?

Traumatic injury to mouth or teeth
Teeth sensitive to cold, heat, sweets or pressure
Bleeding gums.
How Long have the gums been bleeding?
Food Impaction
Clenching or grinding of teeth
Swelling or lumps in mouth
Frequent blisters on lips or mouth
Pain around ear
Bad breath
Complications from extractions
Topical Flouride treatment
Orthodontic treatment
Mouth breathing
Oral habits, ie., thumb sucking, fingernail biting, cheek biting, etc…
Texture of toothbrush
Texture description
Frequency of brushing
How often does the child brush?
Dental floss
Disclosing tablets or solution
Flouride supplements
Between meal snack
Well balanced diet

Medical History

Physician’s Name
Date of Last Physical Exam.
Child’s Age

Does the child have, has had or use any of the following?

Allergies to drugs?
Which drugs?
Allergy to latex
Allergy to anesthetics
Any heart ailments
Radiation treatments
Excessive bleeding from cut or extraction
Anemia or blood problems
Hay fever or allergies in general
Kidney Problems
Liver problems or hepatitis
Malignancies or Leukemia
Psychiatric care/emotional problems
Rheumatic fever
Physical or mental handicap
Thyroid disorders
Eye disorders
Ulcer ot colitis
Extreme nervousness or apprehension
Other description
Describe any current medical treatment, including drugs taken, not included above

Medical History Summary

Existing Illness
Existing Illness
Current Drugs
Nutritional Eval

Dental History Summary

Cheif Complaint
Cheif Complaint
Oral Habits