Star Smiles Childrens Dentistry

Patient Health History

Downloadable Forms Here
Las Formas telecargables Aquí

Please enter the following information into the form, and press the "Submit" button at the bottom of the page.

(*) indicates a required field

Patient Information

E-mail: *

Patient Name: *

Gender: * Male Female

Address: *

City: *

State: *

Zip: *

How long at this address:

Home Phone: *

Birthdate: *

Age: *

If patient is a minor, give parent's or guardian's name:

Employer:

Work Phone:

Occupation:

Time here:

Spouse Name:

Spouse Birthdate:

Spouse Employer:

Spouse Occupation:

Time here:

Whom may we thank for referring you to our office?

Is this your:

Responsible Party / Billing Information

Responsible Party Name:

Address:

City:

State:

Zip:

How long at this address:

Home Phone:

Work Phone:

Birthdate:

Relationship to patient:

Employer:

Occupation:

Time here:

Spouse Name:

Spouse Birthdate:

Spouse Employer:

Spouse Occupation:

Time here:

Dental Insurance Information

Insured's Name:

Birthdate:

Insured's Employer:

Dental Insurance Company:

Group Number:

Insurance Phone:

Address:

City:

State:

Zip:

Do you have dual coverage? Yes No

Insured's Name:

Birthdate:

Insured's Employer:

Dental Insurance Company:

Group Number:

Insurance Phone:

Address:

City:

State:

Zip:

Medical History

Patient's primary care physician:

Physician's Phone:

How would you describe your child's overall health?

When was the child's last physical?

Has your child been hospitalized under a physician's care in the last two years?
Yes No

If so, why?

Is your child currently taking any medications? Yes No

If so, please list each medication:

Has your child ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)

None Aspirin Codeine

Erythromycin Iodine Latex

Novocaine Nitrous Oxide Penicillin

Sulfa Drugs Tetracycline Valium

Xylocaine

Others:

Has the patient ever had any of the following? (Please check all that apply)
None Arthritis or Gout Artificial Joint Asthma or Allergies
Bleeding Problem or Anemia Blood disease Blood Transfusion
Bruise Easily Cancer Cold Sores Congenital Heart Problems
Currently Pregnant Diabetes Dizziness or Fainting
Drug/Alcohol Addiction Eating Disorder Emphysema
Epilepsy or Seizures Fever Blisters Frequent Thirst
Frequent Urination Glaucoma Heart Attack or Stroke Heart Murmur
Heart Trouble Heart Valve or Pacemaker Hepatitis (A) Hepatitis (B)
Hepatitis (C) Herpes High/Low Blood Pressure HIV-AIDS-ARC
Hypoglycemia Jaw Joint Pain Kidney or Liver Disease Lung Disease
Psychiatric Care Radiation/Chemotherapy Rheumatic Fever
Sinus Problems Thyroid Problems Tuberculosis Tumor or Growth
Ulcers or G.I. Problems Use Tobacco X-ray/Chemotherapy

Does your child have any condition or problem not listed which we should know about? Please explain:

Has your child ever been given antibiotics before dental treatment?

Yes

Dental History

Reason for this visit?

Is this your child's first dental visit? Yes No

If no, date of last visit:

Date of last x-ray:

Work done:

Name of former dentist:

Phone:

Type of dentist:

Was your child breast fed?
Yes No Currently

If yes, until what age?

Was your child bottle fed?
Yes No Currently

If yes, until what age?

Has your child ever had any injuries to his or her teeth, mouth, head or jaws?
Yes No

If yes, please describe:

Does your child brush daily? Yes No

Does an adult assist with brushing Yes No

Does your child floss? Yes No

Does an adult assist with flossing? Yes No

Does your child have any of the following mouth habits:
None Finger Sucking Mouth Breathing Teeth Grinding
Lip Sucking Nail Biting Pacifier Tongue Thrusting

Other:

Does your child receive fluoride in any of the following forms:
Vitamins Water Supply Tooth Paste Tablets/Drops Rinse/Gel

Other:

Has your child had any bad dental or medical experiences in the past?
Yes No

If yes, please explain:

Please check any of the following that may describe your child:
Outgoing Cooperative Shy Mellow Anxious Curious
Hyper Stubborn Defiant Friendly Trusting Moody
Suspicious

Child's interests:

Favorite sport:

Favorite movie:

How can we make this a more positive experience for your child?

Nearest Relative

Name of nearest relative not living with you?

Phone:

Address:

City:

State:

Zip:

We welcome patients that are disabled or handicapped. Our dentist is trained to help patients with autism, muscular dystrophy, cerebral palsy, cleft palate and more.

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