Fillable Child Registration and Health History

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Child Registration and Health History

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The Child Registration and Health History form is 2 pages long and contains:

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  • 84 check-boxes
  • 112 other fields

Country of origin: OTHERS
File type: PDF

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Child Registration and Health History
Tell us about your child
Today’s Date: ______/_______/___________
Child’s Name: ___________________________________________
Last First MI
Preferred Name:__________________ Male or Female (circle one)
Child’s Age: ______ Child’s Date of Birth:____/_____/__________
School: ______________________________ Grade: __________
Child LIVES with: ________________________________________
Name
_____________________________________________________________
Address
_____________________________________________________________
City State Zip
Who is accompanying your child TODAY?
_________________________________________________________________________________
Name Relationship
Do you have legal custody of this child? Yes No
How did you hear about us?
(please select one)
Mailer
Billboard
Phone Book
Internet
Referral
(whom can we thank?)_________________________________
Other
(please list)_________________________________________
Mother’s Information: Biological Stepmother Legal Guardian
Name: ________________________________________________
Employer:______________________________________________
SSN: ______-____-________
DOB: ____/_____/_________
Home Phone: _________________ Cell Phone:______________
Work Phone: __________________
Email:______________________________(Confidential! -reminder messages)
Father’s Information: Biological Stepfather Legal Guardian
Name: ________________________________________________
Employer:______________________________________________
SSN: _________-_______-_____________
DOB: _______/_______/____________
Home Phone: _________________ Cell Phone:______________
Work Phone: __________________
Email:______________________________(Confidential! -reminder messages)
Person Responsible for Account (If different from above)
Name:________________________________________________
Relationship to Patient:__________________________________
Billing Address: _________________________________________
Address
______________________________________________________
City State Zip
Contact Phone:________________________
Employer:______________________________________________
Primary Dental Insurance
Insurance Company Name:__________________________________
Insurance Company Address:________________________________
________________________________________________________
Insurance Co. Phone:________________________
Group # ____________________Policy #:______________________
Insured’s Name:__________________________________________
Relationship to Patient:____________________________________
Insured’s DOB:
______/______/________
Insured’s SSN:_______-_______-_____________
Insured’s Employer:_______________________________________
Employer Phone:_________________________________________
Orthodontic Coverage? Yes No
Secondary Dental Insurance
Insurance Company Name:__________________________________
Insurance Company Address:________________________________
________________________________________________________
Insurance Co. Phone:________________________
Group # ____________________Policy #:______________________
Insured’s Name:__________________________________________
Relationship to Patient:____________________________________
Insured’s DOB:______/______/________
Insured’s SSN:_______-_______-_____________
Insured’s Employer:_______________________________________
Employer Phone:_________________________________________
Orthodontic Coverage? Yes No
Other Adult Contacts
(These are used for reminder calls if primary phone numbers cannot be reached)
Name:_________________________________________________
Home Phone:________________ Cell Phone:_________________
Work Phone:_________________
Relationship to Patient:____________________________________
Name:_________________________________________________
Home Phone:________________ Cell Phone:_________________
Work Phone:_________________
Relationship to Patient:____________________________________
I understand that the information given is correct to the best
of my knowledge and that it will be held in the strictest of
confidence. It is my responsibility to inform this office of any
changes in my child’s address, dental insurance and/or
contact information.
______________________________________________________
Signature of parent or guardian Date
click to sign
signature
click to edit
Child Registration and Health History
Medical History
Select One
Is your child currently being treated by a physician? Y or N
If yes, explain:_____________________________
Name of Physician__________________________
Is your child receiving any medications? Y or N
(List current medications in box to right)
Is your child allergic to any medications? Y or N
(List allergies to medication in box to right)
Does your child have other allergies? Y or N
(List other allergies in box to right)
Has your child had any serious illnesses? Y or N
(List serious illnesses in box to right)
Has your child ever had surgery or been hospitalized? Y or N
If yes, explain:_______________________________
Any complications? __________________________
Has your child had any history of any of the following?
Heart trouble, Murmur, or Heart Surgery? Y or N
-Have you been instructed to take a premed by your Physician? Y or N
Asthma, TB, or other Breathing Issues? Y or N
ADD/ADHD? Y or N
Bleeding Disorders? Y or N
Latex or Rubber Allergies? Y or N
Cerebral Palsy or Developmental Delays? Y or N
Speech or Hearing Problems? Y or N
Emotional or Psychological Issues? Y or N
Congenital Birth Defects? Y or N
Cleft Lip and/or Palate? Y or N
Syndrome or Genetic Disturbance? Y or N
Epilepsy, Seizure Disorder, Fainting? Y or N
Rheumatic or Scarlet Fever? Y or N
Sickle Cell Anemia or Blood Disorder? Y or N
Thyroid or other Glandular Issue? Y or N
Diabetes? Y or N
Cancer, Tumor, or Leukemia? Y or N
HIV Infection or AIDS? Y or N
Malignant Hypothermia?
(or family history of this) Y or N
Other Medical Conditions Not Listed Above? Y or N
(List if Yes)_________________________________
Dental History
When and where was your child’s last dental visit?______________
_______________________________________________________
Were any x-rays taken? Y or N
Did your child have difficulty cooperating? Y or N
When does your child get his/her teeth brushed?
____ Morning ____ After eating ____ Before Bed
Does your child get assistance/supervision? Y or N
Has your child had any cavities in the past? Y or N
Have either parents had problems with cavities? Y or N
Have there been any injuries to your child’s teeth? Y or N
Do you expect your child to cooperate? Y or N
Current Medications: ____________________________________
____________________________________
____________________________________
Drug Allergies:__________________________________________
Other Allergies:_________________________________________
Serious Illnesses:________________________________________
______________________________________________________
Consent
I understand that the above information is correct to the best of my
knowledge, and that it will be held in the strictest of confidence. Because
my child is a minor, it is necessary that signed permission be obtained
from a parent or guardian before any dental services can be rendered. I
give my consent to Dr. Garrison & Dr. Allen-Steed, and their dental team
to perform such treatment, services, medication, behavior management
techniques, local anesthesia and/or analgesia necessary to treat any
dental/oral deficiency, abnormality, and/or infection.
____________________________________________________________
Signature of Parent/Guardian Relationship to Patient Date
Office Use
Medical and Dental History Reviewed ______________________________________
Dentist Signature Date
Office Use Only
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________
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Child Registration and Health History

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Completed 21 April 2022

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