Pediatric Dental Health History Form
Patient Information
Child's Name
Date of Birth
Gender
Female
Male
Other
Parent/Guardian Name
Contact Number
Address
Medical History
Child's Physician
Physician Phone
Any known medical conditions?
Allergies (medications, foods, etc.)
Current medications
Past hospitalizations or surgeries
Dental History
Previous Dentist
Date of Last Dental Visit
Any dental concerns?
Oral habits (thumb sucking, pacifier, etc.)
History of dental injury?
How often does your child brush teeth?
How often does your child floss?
Additional Information
Anything else we should know?