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Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Contact Information

Preferred Method of Contact

Health History

Does your child have any medical conditions or disabilities?
Have you ever been told your child needs antibiotics before a dental visit?
Has your child ever had heart or cardiac problems?
Has your child had any surgeries or hospital visits?
Does your child take any medications on a daily basis?
Does your child have any food or medication allergies?
Is your child allergic to latex, pine nuts, or dairy products?
Does your child have asthma or reactive airway disease?
Please select all the conditions your child currently has, or HAS HAD in the past.
Does your child have any physical or mental disabilities or speech problems?

Dental History

Is this your child's first visit to the dentist?
How do you think your child will do at this visit?
Has your child ever had a negative dental experience in the past?
Has your child had a toothache recently?
Does your child have any of the following habits?
What type of water does your child drink?
Has your child ever had any injuries to the jaw, head, mouth, or teeth?


NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.