Child Health History Form Submit your health history form online to your dentist today. Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.About Your ChildChild's Full Name* First Last Sex*MaleFemaleAge*Birthdate* Date Format: MM slash DD slash YYYY Reason for Visit*Referred To This Office By:Full NamePhone NumberDental HistoryChild's First Dental Visit?*YesNoPrevious DentistPrevious Dentist CityDate of Last VisitDate of Last X-raysAny injuries to the teeth or jaws?YesNoIf yes, whenDoes Your Child Receive: Fluoride in vitamins Fluoridated water Gummy vitamins Fluoride tabs/drops None Has your child experienced any unfavorable reaction from previous medical or dental care?YesNoIf yes, explainHow do you think your child will act towards the dentist?Medical HistoryChild's Physician/Pediatrician's Name*PhoneIs your child presently under the care of a specialist for any medical reason?*YesNoIf yes, what?Specialist's Name*PhoneDoes your child have a history of health problems?*YesNoIf yes, explain?Are antibiotics necessary for dental work because of a heart murmur, heart defect, prosthesis, shunt or other medical reason?*YesNoIf yes, explain?Is your child presently taking any medications?*YesNoIf yes, explain?Has your child had a history of taking frequent medications?*YesNoIf yes, explain?Has your child been hospitalized or had surgery?*YesNoIf yes, explain?Is your child allergic to any drugs?*YesNoIf yes, explain?Is your child allergic to any foods?*YesNoIf yes, explain?Is your child allergic to any medications or dyes?*YesNoIf yes, explain?Is your child allergic to any environmental pollutants?*YesNoIf yes, explain?Is your child allergic to any latex, metals, or acrylics?*YesNoIf yes, explain?Has any family member, including your child had a problem with general anesthetic?*YesNoIf yes, explain?Has your child ever been diagnosed as having any of the following conditions? Check Yes or No.ADHD/ADD*YesNoAIDS/HIV*YesNoAnemia*YesNoArthritis*YesNoAsthma*YesNoAutism*YesNoBladder Conditions*YesNoBlood Disease*YesNoBlood Transfusions*YesNoBirth Defects*YesNoBone or Joint Problems*YesNoBrain Injury*YesNoBruising Easily*YesNoCancer or Malignancies*YesNoCerebral Palsy*YesNoChemotherapy/Radiation*YesNoChild Abuse*YesNoChronic Adenoid/Tonsil Infections*YesNoChronic Ear Infections*YesNoCleft Lip/Palate*YesNoCongenital Heart Lesion*YesNoConvulsions/Seizures*YesNoDevelopmentally Delayed*YesNoDiabetes*YesNoDrug Addiction*YesNoEar Stuffiness, Itching, or Noises*YesNoEmotional Disturbance*YesNoEpilepsy*YesNoEye Problems*YesNoExcessive Bleeding Problem*YesNoExcessive Gagging*YesNoFainting or Dizziness*YesNoFever Blisters*YesNoGrowth/Developmental Problems*YesNoHeart Surgery*YesNoHeadaches*YesNoHearing/Speech Impairments*YesNoHeart Murmur/Defects*YesNoHemophilia*YesNoHepatitis/Liver Disease*YesNoHigh Blood Pressure*YesNoKidney Disease*YesNoLeukemia*YesNoMental Disability*YesNoMouth Sores*YesNoNutritional Deficiency*YesNoOrthopedic Problems*YesNoPain in Jaw Joints*YesNoPremature Birth*YesNoPsychiatric Care*YesNoRheumatic Fever*YesNoScoliosis*YesNoSickle Cell Anemia*YesNoTuberculosis*YesNoSyndrome*YesNoIf yes, explain?Other*YesNoIf yes, explain?Do you wish to talk to the doctor privately about a special concern?*Responsible Party Parent/GuardianParent/Guardian Full NameParent/Guardian Date of Birth Date Format: MM slash DD slash YYYY Parent/Guardian Social SecurityAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneBusiness PhoneEmail EmployerOccupationParent/Guardian Full NameParent/Guardian Date of Birth Date Format: MM slash DD slash YYYY Parent/Guardian Social SecurityAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneCell PhoneBusiness PhoneEmail EmployerOccupationIs patient living with both parents?*YesNoIf no, with whom does the child reside?SiblingsName First Last Birthdate Date Format: MM slash DD slash YYYY Name First Last Birthdate Date Format: MM slash DD slash YYYY Name First Last Birthdate Date Format: MM slash DD slash YYYY Dental Insurance InformationPrimary Dental InsuranceGroup No.Insurance ID NumberPolicy Holder NameSecondary Dental InsuranceGroup No.Insurance ID NumberPolicy Holder NameConsent for Treatment* I am the (parent/guardian) of the child listed above who is a minor child, and I authorize examination and treatment as necessary by or under the supervision of Growing Smiles. This includes exposure of radiographs as necessary, use of local anesthesia, inhalation and oral medication, responsible restraint as needed, and use of appropriate medicaments and materials for such treatment. If I have any objections to certain aspects of treatment. I have stated so in the space provided below. I will assume responsibility for fees associated with those procedures for my child. SignaturePLEASE NOTE: Payment is expected for service rendered at the time of treatment. If the family is not living together, the parent bringing the child is responsible for the child's account.Date* Date Format: MM slash DD slash YYYY School InformationName of Preschool or Elementary School your child attends or will attend:Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!