Student Dental Health History Form
Student Information
Full Name
Date of Birth
Grade
Address
Parent/Guardian Name
Phone Number
Parent/Guardian Email
Dentist Information
Dentist Name
Date of Last Dental Visit
Dental History
Has the student experienced any of the following? (Check all that apply)
Cavities
Toothache
Gum Problems
Mouth Injury
Braces
None
Describe any current dental concerns
Medical History
Has the student ever had any of the following? (Check all that apply)
Allergies
Asthma
Diabetes
Heart Conditions
Bleeding Disorders
Other
None
If yes to any, please provide details
Is the student currently taking any medications?
Consent & Signature
Consent to treatment
Parent/Guardian Signature
Date