!
!
!
!
!
!
!
!
!
"#$%&'()!*#()+*!*,%+&$-!&./!
!
!
!
"#$%&'(!)*+,!! !
!
!
!
)$-./*+,!!
!
!
!
!
0,1!!
2*3,!45!6$73#!!
!
!
!
8%*-,!! !
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!!!!!!!!!!!!!!!!
!
!
!
!!!!!!!!!!!!!!!!!!!!!!!
<$=!
!
!
!
!
!
!F-!G!
!
!
!
!
!
!
94+,!:&&7,((!! !
!
!
037,,3!
>*3#,7'(!)*+,!! !
!
>*3#,7!,+=%4;,&!C;!!
!
8#4/,E!F#G!
!
!
!
!
!
?43#,7'(!)*+,! !
!
!
!
!
!
?43#,7!I+=%4;,&!C;!!
!
!
!
!
8#4/,!F#G!
!
!
!F-G!
!
!
!
!
?*7$3*%!03*3D(E!?*77$,&!! !
!!2$J47-,&!!
!
)*+,!*/&!C$73#&*3,(!45!B3#,7!"#$%&7,/E!! !
!
!
!
!
!
!
!
!
2@A!!
03*3,!
!
!!04-$*%!0,-D7$3;!)4A!!
!
!
!
!
!
!FHG!
!
!
!I+*$%E! !
!
!
!
!
!
?0A!!
!
?@0A!
!
2@A!
!
B3#,7!!
!
!!04-$*%!0,-D7$3;!)4A!!
!
!
!
!
!
FHG!
!I+*$%E! !
!
!
!
!
!
!
"$3;!!
?@A!!
!
B3#,7!! !
!
!
!
!!!!!!!!K$&4H,&!!
!
!!0$/L%,!! !
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
)*+,!*/&!:&&7,((!45!"#$%&'(!8#;($-$*/M8,&$*37$-$*/!! !
!
!
!
!
!
!
!
!
!
!
!
!
)*+,!! !
!
!
8#4/,!
!
!
!
!
!
!
!
!
!
!
!
!
!
:&&7,((!
!
)*+,!*/&!:&&7,((!45!87,J$4D(!2,/3$(3!*/&!2*3,!45!N$($3!!
!
!
!
!
!
!
!
!
!
!
!
!
!!!!!!)*+,!
!
!
8#4/,!
!
!
!
!
!
!
!
!
!
!
!
!
!
:&&7,((! !
!
!
!
!
!
!
2*3,!45!O*(3!N$($3!!!
!
@,5,77,&!C;E!!
!
!
!
!
!
!
!
!
!
!
!
!
!
P(!;4D7!-#$%&!-4J,7,&!C;!&,/3*%!$/(D7*/-,Q! !
R,(!
!!!!!!!!!!!)4!
!
87$+*7;!P/(D7*/-,!!
!
!
!
!
S74D=!T!!
!
!!!!!!!!!!!?4+!!!!!!!!!!2*&!
!
P2!T!!
!
!
!
!
0DC(-7$C,7'(!2*3,!45!6$73#!!!
!
!
!
!
!
0,-4/&*7;!P/(D7*/-,!!
!
!
!
!
S74D=!T!!
!
!!!!!!!!!!?4+!!!!!!!!!!!2*&!!
!
P2!T!!
!
!
!
!
0DC(-7$C,7'(!2*3,!45!6$73#!!!
!
!
!
!
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Conditions of child’s health Has your child had …. (circle all that apply) Heart trouble, rheumatic fever, glandular problems, brain injury, asthma, seizures, bleeding disorders, skin disorders, ear infections, diabetes, hyperactivity, kidney or liver problem, tuberculosis, headaches, emotional or psychiatric illness. Has your child ever had any hearing, sight, speech, coordination problems or special schooling? If so, state what problem is and when it existed. Has your child ever been hospitalized? Please list Has your child had any kind of surgery? Please list Has your child ever received a blood transfusions? Does your child have any blood-­‐borne diseases? Does your child need antibiotics for dental treatment? Please indicate any other health problems. Is your child taking any pills or medication now? Did your child receive medication as an infant? Is your child allergic to any food or medicine? Is your child allergic to latex? Was the term of pregnancy and birth normal for your child? If no, please state any complications or problems including prematurity or low birth weight. Is this your child’s first visit to the dentist? If not, when was the last visit to the dentist? Xrays? Has your child ever experienced an unfavorable or undesirable reaction to previous dental or medical care? Does any member of the family have any missing or extra teeth? What do you think of the condition of your child’s mouth? Are you concerned about any special dental problems now? Is your child experiencing any dental pain or discomfort now? At what age did teeth first appear? Where? upper lower front back Was your child bottle-­‐fed or breast-­‐fed? Has there ever been an injury to any of your child’s teeth? Please circle all habits that your child has ever had: finger-­‐sucking pacifier mouth-­‐breathing grinding other Please circle any of the following that are sources of fluoride for your child: water toothpaste vitamin supplements fluoride supplements Do you have well water? (if yes, please bring in a sample) Is bottled water a primary source of cooking or drinking? Please list any questions you would like answered: Your signature indicates that you have completed the health history to the best of your knowledge. Parent or guardian signature Date