Child History WNY

Please answer the following items as completely as possible. Please complete all sections that apply. Click the 'Submit' button at the bottom of the form when you are finished. Thank you!

Child Health History WNY

Today's Date:*

Child's First Name:*

Child's Last Name:*

Child's Birthdate:*

Child's Guardian Name:*

Guardian Phone:

Physician Name:

Physician Phone:

Last Physician Exam:

Any Serious Illness:

Yes

Describe Illness:

Any Hospitalizations:

Yes

Describe Hospitalizations:

Any Medications:

Yes

List Medications:

Has your child ever had an allergic reaction or
sensitivity reason to the following:

Dental Anesthetics

Antibiotics

Food

Drugs

Latex

Nickel

Other

None

If Other checked, please
describe:

If any checked, please
describe reaction:

Has your child ever received
a blow or injury to his head
or teeth?

Yes

If yes, describe:

Has your child ever had any of the following conditions?

Please check all that apply.

ADD/ADHD

At Age:

Anxiety

At Age:

Asthma

At Age:

Austism

At Age:

Bleeding

At Age:

Cancer

At Age:

Diabetes

At Age:

Epilepsy

At Age:

Hearing Loss

At Age:

Heart Condition

At Age:

Hepatitis

At Age:

HIV AIDS

At Age:

Kidney Disease

At Age:

Learning Disability

At Age:

Lung Disease

At Age:

Mental Disability

At Age:

Mononucleosis

At Age:

Neurologic Disorder

At Age:

Scarlet Fever

At Age:

Sensory Issue

At Age:

Sickle Cell Anemia

At Age:

Other Conditions:

General Comments:

Additional Comments:

Brushes How Often:

Flosses How Often:

Does your child have any habits we should be aware of?

Poor Eating Habits

Thumb Sucking

Pacifier

Bottles

Other

If other habits,
please describe:

Does your child receive fluoride in:

Drinking water at home:

Yes

By prescription:

Yes

Has your child had any
unpleasant dental
experiences?

Yes

How can we help?

Date of last dental
examination:

Previous Dentist's Name:

Has your child ever had
orthodontic treatment?

Yes

When:

Where:

What is the nature
of today's visit?

Today's Problem:

I understand the above information is necessary to provide
me with dental care in a safe and efficient manner. I have
answered all questions to the best of my knowledge.
Should further information be needed, you have my
permission to ask the respective health care provider or
agency, who may release such information to you. I will
notify the doctor of any changes in my health or medication.

I consent to the doctor's exam and necessary
diagnostics for treatment including x-rays:

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