Children's Hospital Boston

Dentistry Patient Health History

*Denotes Required Field

Parent Information and Health History Form

Child's Name*
Nickname
Interests/Hobbies/Pets
Sex*	Male Female
Age*
Birthdate*	(ex. mm/dd/yyyy)
Mailing Address*
City*
State*
Zip*
Home Phone*

Mother's Name*		Occupation		Work Phone

Father's Name		Occupation		Work Phone

Father's Address (if different from above)

What is the parent's primary language?*

The child's?*

Date of Adoption, if applicable	(ex. mm/dd/yyyy)

Names and ages of brothers and sisters

Whom may we thank for referring you?

Whom may we contact in case of emergency?

Name*
Relationship*
Phone*

Health Providers

Child's Physician/Pediatrician*
Phone #*
Mailing Address
City
State
Zip

Children's Hospital Clinics attended by child


Child's Previous Dentist
Phone #
Mailing Address
City
State
Zip

Medical History

1. Were there any difficulties during the pregnancy, delivery (e.g. prematurity) or
1st year of your child's life? Yes No

If yes, describe

2. Medical conditions: Does your child have any history of the following? (Check all that apply)

General conditions

Arthritis

Asthma

Diabetes

Gastrointestinal disorders

Heart disease

Heart murmur

Kidney disease

Rheumatic fever

Behavior/Learning

ADHD

Anxiousness/Nervousness

Autism

Behavior issues: Type

Emotional disability: Type

Learning disability: Type

Psychiatric disorder: Type

Developmental

Brain injury

Cerebral palsy

Cleft lif/palate

Developmental Delay

Feeding/Eating problems

Growth problems

Hearing loss: Type

Neuromuscular defect

Orthopedic problems

Seizures: Type

Speech prob: Type

Spina bifida

Hematological (Blood-related)

Anemia

Bleeding (prolonged)

Hemophilia

Sickle cell trait

Sickle cell disease

Transfusion of blood

Infections

Hepatitis

HIV infection (AIDS)

Tuberculosis

Venereal disease: Type

Substance use/Abuse

Drug use

Tobacco use

Abuse (physical or sexual)

Other

Cancer: Type

Leukemia: Type

Fainting/headaches (often)

Sleep apnea

Sleep problems

Snoring

Syndrome: Type

Other:

If any boxes checked, please describe further

3. Medications: Is your child CURRENTLY taking any medications?

Drug	How much & how often?	Reason

4. Steroid Use: Has your child had any steroid treatment in the past 6 months?* Yes No

5. Allergies: Has your child had any allergic reactions to


Medications or drugs?*	Yes No
If yes, describe:
Latex?*	Yes No
If yes, describe:
Food?*	Yes No
If yes, describe:
Other?*	Yes No
If yes, describe:

6. Development/Special needs:

Can your child talk and understand at his/her age level?*	Yes No
Does your child attend a special class or school?*	Yes No
If yes:
Does your child use the following to help with walking?	Wheelchair Walker Other
If female, has your child had her first monthly period?	Yes No

7. Immunizations: Are your child's immunizations current?* Yes No

8. Have you ever been told that your child needs to take antibiotics before dental treatment?*

Yes No

9. Hospitalizations:

Has your child ever been hospitalized?* Yes No
If yes, when, and where?

Reason for hospitalization?

10. Surgeries:

Has your child had any surgery (operations)?* Yes No
Date(s) and age(s)?

For what reason(s)?

Was general anesthesia used? Yes No
Were there any complications? Yes No
If yes:

11. Are there any elevated stresses happening in your home?* Yes No

If yes:

12. Have you or your child ever felt threatened in your home?* Yes No

Dental History

13. Why is your child here today?*

14. If your child has been to a dentist previously:

When was last visit?
Have X-rays been taken?	Yes No
When?

15. How did your child react?

16. Has your child had local anesthetic ("Novocaine")?* Yes No

Were there any problems?

17. Fluoride: Has your child had fluoride in any of the following forms?

Fluoride tablets or fluoride multivitamins* Yes No
Drinking water (community water fluoridation)* Yes No
Professional topical application* Yes No

18. Brushing:

Does your child brush his/her own teeth?* Yes No
When does he/she brush?* A.M. P.M. After meals
Do you help in brushing your child's teeth?* Yes No
Do you or your child use dental floss in cleaning their teeth?* Yes No
What kind of toothbrush does he or she use?* Hard Soft Battery

19. Diet:

Does your child snack frequently?* Yes No
If yes, what do those snacks usually consist of?

How much soda and juice does your child usually drink per day?

20. Trauma:

Have your child's teeth ever been injured?* Yes No
When (age)?

Which teeth?

Cause?

Did he/she receive treatment? Yes No
If yes, describe treatment?

21. Habits: Does your child have any of the following habits? (Indicate inclusive ages)

Bottle to sleep or nap* Yes No
If yes, bottle contains
Thumb or finger sucking* YesNo
Pacifier sucking* Yes No
Mouth breathing* Yes No
Grinding of teeth* Yes No

22. Has your child received any unusual dental or surgical treathment to the mouth?*

Yes No

If yes, describe?

23. Is there anything else you want to tell us?

Completed By*

Name of person completing this form



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