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Child Health History Form

Your child's overall health as well as any medications which your child takes could have an important inter-relationship
with the dental care your child receives. Please answer each of the following questions completely.

 

Has your child ever had any of the following? Check all the apply
AsthmaRheumatic FeverCancerCongenital Heart DefectHepatitisHandicaps/DisabilitiesHIV/AIDS
Convulsions/EpilepsyHemophiliaTuberculosisDiabetesAbnormal BleedingAllergiesHeart Murmur

Child's Habits

 

 

 

Is your child's water fluoridated? YesNo

Take fluoride supplements? YesNo

Does You Child?

Suck thumb/fingerBite/Chew nailsGrind teethSuck/Bite lipsChew hard objectsClench jaw

Authorization and Release

To the best of my knowledge, the questions on this for have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I authorized the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental group insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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Bedford Family & Laser Dentistry