Child's Health History Form

Patient Info > Patient Forms > Child Health History Form
CHILD’S HEALTH HISTORY FORM
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For the following questions, please select whichever applies.
Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note 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 clinic does not use this information to discriminate.
Do you have any of the following conditions? SELECT YES, NO, or UNSURE
PLEASE MAKE SURE THAT EVERY BOX IS CHECKED
MEDICAL INFORMATION













































































PREMEDICATION INFROMATION / DENTAL HISTORY







PATIENT/GUARDIAN SIGNATURE
To the best of my knowledge, the indicated health history remains current. I understand that any change in the patient’s health or medication requires that an updated form be completed.

Note: Both doctor and parent are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form