Child History UDA

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 UDA

Today's Date:*

Child's First Name:*

Child's Last Name:*

Birthdate:*

Current Age:

Birth Sex:

Male

Female

Nickname:

Guardian's Name:

Relationship:

Phone:

Child's Physician:

Phone:

Date of last physical exam:

How is your child's general
health?

Has your child had any
serious illness?

Yes

If yes, describe:

Is your child receiving any
medication at this time?

Yes

For what reason?

Is child adopted?

Yes

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

Dental Anesthetics

Antibiotics

Food

Drugs

Latex

Nickel

None

If any checked, please
describe:

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

COVID 19

Anemia

Anxiety

Asthma

Autism

Bleeding Disorder

Cancer

Cancer Type:

Cerebral Palsy

Chronic Ear Infections

Cleft Lip Palate

Cystic Fibrosis

Delayed Speech

Delayed Development

Diabetes

Diabetes Type I

Diabetes Type II

Down Syndrome

Emotional Problems

Epilepsy

Feeding Tube

Hearing Problems

Heart Condition

Heart Murmur

Hepatitis

Hepatitis A

Hepatitis B

Hepatitis C

HIV or AIDS

Kidney Disease

Learning Disability

Liver Disease

Muscular Dystrophy

Mental Disabilities

Radiation Therapy

Rheumatic Fever

Seizures

Sickle Cell Anemia

Skin Disorders

Sleep Apnea

Snoring

Other Syndromes:

Other Conditions:

General Comments:

Does your child have any habits we should know about,
such as:

Poor Eating Habits

Thumb Sucking

Pacifier

Bottles

Nail Biting

If other,
please describe:

Family Dental History:

Missing Teeth

Extra Teeth

Dental Decay

Underbite

Overbite

Jaw Surgery:

Other family dental history:

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:

Other Comments:

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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