Child Medical History Form

Complete and accurate information helps us tailor your child's care from the first appointment. Please fill out the form thoroughly so we can understand your child's medical history, dental needs, and preferences ahead of your child's visit. This will help ensure a smoother, more personalized experience.

Patient Name*:

DOB*:

Address*:

Legal Guardian*:

Phone*:

Legal Guardian:

Phone:

Email*:

Indian Status #:

Siblings Names:

Insurance Information

Insurance Provider

Policy #:

ID #:

Medical History

Has your child been hospitalized in the past 2 years? If so for what?

Does your child have any allergies?

Does your child take any medications?

Does your child have any medical conditions?

Nervous or emotional disorders

Respiratory or breathing problems

Diabetes

Heart Disease

Hepatitis

HIV / Aids

Tuberculosis

Rheumatic Fever

Epilepsy

Cancer

Chronic Headaches

Fainting / Dizziness

Kidney Disease

Blood Disorder

Other

Is your child under the care of an Orthodontist?

Has your child ever had any problem with dental treatment in the past? If yes, please describe:

I understand it is my responsibility to inform the staff of any changes to my child’s health.

Guardian Signature:

Date