Health History Update Health History Update Child’s Name Child's Name First First Middle Middle Last Last Goes By Nickname Date of Birth * Age Gender Male Female Medicaid or Texas CHIP * Yes No Medicaid / ID Number Home Address * Home Address Home Address Home Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Reason for today’s visit (check all that apply) Check-up Cavity Pain Accident OtherOther Name of person who is accompanying your child today? * Relationship to patient Parent Step-Parent Grandparent Other Relationship to patient Does this person have legal custody of this child? * Yes No Phone of legal guardian * Email of a legal guardian * Medical History Update Any changes in medical history or illnesses? * No Yes (please explain)Yes (please explain) List current medications (including herbal) Is there any allergy to penicillin or other drugs? * No Yes (please list)Yes (please list) Are there any other allergies? * No Latex Metal Food Pollen Animals Dust Dye Other:Other: Do you have any dental concerns? * No YesYes Would you be interested in discussing straightening your teeth with clear aligners (Invisalign) today? * No Yes *Note: this would not be covered by your insurance* Has this child had any treatment on any of the following? Blood/ Circulatory No Yes Gastrointestinal (stomach) No Yes Muscles No Yes Endocrine glands No Yes Kidney / Bladder No Yes Nervous System No Yes Eyes, Ears, Nose, Throat No Yes Liver No Yes Skin No Yes Has this child ever been diagnosed as having any of the following conditions? ADD No Yes Epilepsy No Yes Pneumonia No Yes ADHD No Yes Eye Problems No Yes Pregnancy No Yes AIDS / HIV No Yes Excessive Bleeding Problem No Yes Rheumatic Fever No Yes Seasonal Allergies No Yes Fainting No Yes Scarlet Fever No Yes Anemia No Yes Fetal Alcohol Syndrome / NAS No Yes Scoliosis No Yes Arthritis No Yes Head Trauma No Yes Seizures No Yes Asthma No Yes Hearing Loss No Yes Sickle Cell Anemia No Yes Autism Spectrum Disorder No Yes Heart Disease No Yes Sinus Problems No Yes Brain Injury No Yes Heart Murmur No Yes Sleep Apnea No Yes Bronchitis No Yes Hemophilia No Yes Snoring at Night No Yes Cancer No Yes Hepatitis No Yes Spina Bifida No Yes Type of Hepatitis * Cerebral Palsy No Yes Jaundice No Yes Syndrome No Yes Explain * Chicken Pox No Yes Leukemia No Yes Tetanus No Yes Cleft Lip / Cleft Palate No Yes Measles No Yes Thyroid No Yes Congenital Birth Defect No Yes MRSA No Yes Tuberculosis No Yes Developmentally Delayed No Yes Mumps No Yes Venereal Disease No Yes Diabetes No Yes Mouth Breathing No Yes Whooping Cough No Yes Type of Diabetes * Type 1 Type 2 Drug, Alcohol, Tobacco Use No Yes Nutritional Deficiency No Yes Other No Yes More information * Emotional Disorder No Yes Orthopedic Problems No Yes Services my child is scheduled to receive today: * Routine dental check-up Emergency evaluation Follow-up (for recent treatment / surgery) Dental treatment (fillings, crowns, sealants, extractions, etc) I give my consent for my child to have a * dental exam teeth cleaning fluoride treatment x-rays (A separate consent form is required for fillings, crowns, sealants, extractions, etc) The information I have given is correct to the best of my knowledge and I understand that it will be held in the strictest confidence. I understand that providing incorrect information can be dangerous to my child’s health. I understand it is my responsibility to inform this office of any changes in my child’s medical status. * I authorize the release of information to all of my insurance companies. I understand that I am responsible for all financial responsibilities. * Your name * Relationship to patient * Your email * Signature * Clear If you are human, leave this field blank. Submit Δ
