HEINE FAMILY DENTAL - CHILD NEW PATIENT

Today's Date: * 🛈 +

NOTE: The parent or guardian who accompanies the child is responsible for payment at the time of service.

HEALTH HISTORY FORM

1. Tell Us About Your Child

Child's Name: *

Goes by: *

Sex *

Male

Female

Child's Birthdate: * 🛈 +

Child's Age:

Siblings that we treat:

School:

Grade:

Child's Home #:

Child's SS #:

E-mail Address:

Child's Home Address: *

City: *

State: *

Zip: *

2. Who may we thank for referring you to our office?

3. Mother's Information

Name: *

Relationship to Child: *

Mother

Stepmother

Guardian

Birthdate: * 🛈 +

Employer:

Work #:

Ext:

Home #: *

Cellular Phone #:

SS #:

DL #:

E-mail Address:

4. Father's Information

Name: *

Relationship to Child: *

Father

Stepfather

Guardian

Birthdate: * 🛈 +

Employer:

Work #:

Ext:

Home #: *

Cellular Phone #:

SS #:

DL #:

E-mail Address:

5. Who is Accompanying the Child Today?

Name: *

Relationship: *

Do you have legal custody of this child? *

Yes

6. Person Responsible for Account

Name: *

Relationship: *

Billing Address: *

City: *

State: *

Zip: *

Home #: *

Work #:

Ext:

Cellular Phone #:

E-mail:

7. Primary Dental Insurance

Insurance Co. Name:

Insurance Co. Phone #:

Insurance Co. Address:

Group # (Plan, Local, or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate: 🛈 +

Social Security #:

Policy Owner's Employer:

8. Secondary Dental Insurance

Insurance Co. Name:

Insurance Co. Phone #:

Insurance Co. Address:

Group # (Plan, Local, or Policy #):

Policy Owner's Name:

Relationship to Patient:

Policy Owner's Birthdate: 🛈 +

Social Security #:

Policy Owner's Employer:

9. Dental History

Is this your child's first visit to the dentist?:

If not, how long since the last visit to the dentist?

Previous Dentist's Name:

Were any x-rays taken at previous dental visits?

Yes

Have there been any injuries to the teeth, face or mouth?

Yes

If yes, please explain

Why did you bring the child to the dentist today?

	Yes	No
Lip Sucking/Biting	Yes	No
Nursing/Bottle Habits	Yes	No
Nail Biting	Yes	No
Thumb/Finger Sucking	Yes	No

Has the child ever had a serious or difficult problem associated with previous dental work?

Yes

If yes, please explain

Is the child's water fluoridated?

Yes

Is the child taking fluoride supplements?

Yes

Has the child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TD)?

Yes

Does the child brush his/her teeth daily?

Yes

Floss his/her teeth daily?

Yes

10. Health History

Has the child ever had any of the following conditions?

	Yes	No
Abnormal Bleeding	Yes	No
Allergies to any Drugs	Yes	No
Any Hospital Stays	Yes	No
Any Operations	Yes	No
Asthma	Yes	No
Cancer	Yes	No
Congenital Birth Defects	Yes	No
Convulsions/Epilepsy	Yes	No
Pregnancy	Yes	No
Tuberculosis	Yes	No
ADD/ADHD	Yes	No

	Yes	No
Disabilities/Special Needs	Yes	No
Hearing Impairment	Yes	No
Heart Disease/Murmur	Yes	No
Hemophilia/Blood Disorders	Yes	No
Hepatitis	Yes	No
HIV/AIDS	Yes	No
Kidney/Liver Conditions	Yes	No
Rheumatic/Scarlet Fever	Yes	No
Allergies to Latex Products	Yes	No
Diabetes	Yes	No
Autism	Yes	No

Please discuss any serious medical conditions the child has had:

Please list all drugs the child is currently taking:

Please list all allergies:

Child's Physician

Phone:

Is the child currently under the care of a physician?

Yes

Please describe the child's current physical health:

Good

Fair

Poor

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

11. AUTHORIZATION

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Patient's Signature: *

Date: 🛈 +

Relationship to Patient: *

For Office Use Only

I verbally reviewed the medical/dental information above with the parent/guardian and patient named herein.

Initials:

Date: 🛈 +

Doctor's Comments:

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