Pediatric Dental History Form
Patient Information
Child's Name
Date of Birth
Age
Gender
Male
Female
Other
Parent/Guardian Name
Phone Number
Medical History
Child's Physician
Physician Phone
Medical Conditions
Allergies
Does your child take any medications?
Yes
No
If yes, please list:
Dental History
Is this your child's first dental visit?
Yes
No
Previous Dentist
Date of Last Visit
Dental Concerns/Problems
Does your child have any of the following habits?
Thumb/Finger Sucking
Pacifier
Nail Biting
Tooth Grinding
Others
If others, please specify:
Additional Information
Is there any additional information we should know?