HEALTH HISTORY FORM

HEALTH HISTORY FORM

    Dental History:

    1. Please check reason(s) for seeking dental care:
    First ExaminationRoutine check-upToothache or swellingAppearance of teeth or faceCrowding TeethAccident

    Other

    2. Has your child has been to a dentist previously? YesNo

    a. When was the last visit? YesNo

    b. Have x-rays been taken and when?
    YesNo

    c. How would you describe your child’s temperament?

    3. How do you think your child will react to dental treatment?

    4. Has your child has fluoride in any of the following forms?

    Fluoride tablets or in vitamins (Fluoride amount .25 .5 1.0mg) YesNo

    Drinking water (community fluoridation) YesNo

    Topical application to teeth? YesNo

    When is last

    Toothpaste; brand

    5. Does your child brush his/her own teeth? YesNo

    How frequently and when?
    A.M.P.M.After SnacksBefore BedAfter Breakfast

    6. Do you brush your child’s teeth? YesNo

    How frequently and when?
    A.M.P.M.After SnacksBefore BedAfter Breakfast

    7. Do you or your child use dental floss in cleaning your child’s teeth? YesNo

    How frequently and when?
    A.M.P.M.After SnacksBefore BedAfter Breakfast

    8. Does your child have between meal snacks? YesNo

    9. Have your child’s teeth ever been injured?

    When?

    Cause?

    10. Does your child have any of the following habits? (Indicate ages when occured)

    Bottle to bed at night

    Thumb or finger sucking

    Pacifier

    Tongue thrusting

    Lip sucking or biting

    Breathes through mouth

    11. Has your child received any unusual dental or surgical treatment to the mouth? YesNo

    If so, what?

    Guarantor Information

    FATHER’S INFORMATION

    Name:

    Address:

    Home Phone:

    Relationship to Patient:

    Birthday:

    Social Security Number:

    Occupation:

    Employer:

    Address:

    Work Phone:

    MOTHER’S INFORMATION

    Name:

    Address:

    Home Phone:

    Relationship to Patient:

    Birthday:

    Social Security Number:

    Occupation:

    Employer:

    Address:

    Work Phone:

    In order to control the cost of dental services, we require that payment be made at the time of service, unless otherwise discussed previously with our Financial Coordinator. Payment can be made with cash, personal check, MasterCard or Visa. if for any reason your check is returned to us, there will be an additional fee.

    Please indication person responsible for payment fee:

    Name:

    Billing Address:

    City:

    Zip:

    Home Phone #:

    AUTHORIZATION AND RELEASE

    CONSENT FOR TREATMENT

    To the best of my knowledge, the questions on this form 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 also authorize the dentist to release any information including the diagnosis and the record of treatment or examination rendered to my child during the period of such care to third party payers and/or health practitioners. I authorize the use of radiographs and photographs for the purpose of teaching and scientific publications. I request that my insurance company pay directly to the dentist. I understand that my insurance carrier may pay less that the actual bill for services; therefore, I agree to be responsible for payment of all services rendered on my child’s behalf.

    Signature of Parents/Guardian:

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    Connect with Us

    Fullerton Pediatric Dentistry

    ADDRESS
    100 E. Valencia Mesa Drive, Suite 102
    Fullerton, CA 92835

    PHONE
    714.992.5437 (KIDS)

    WEBSITE
    www.fullertonpediatricdentists.com

    OFFICE HOURS
    Monday-Thursday
    *9:00 AM to 12:00 PM & 2:00 PM to 5:00 PM
    Friday & Saturday
    *By Appointment Only