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UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY
DEPARTMENT OF PEDIATRIC DENTISTRY
HEALTH HISTORY
PATIENT INFORMATION
Child's Name
Mother
Nickname
Father
Date of Birth
Guardian
Address
City
SS #
Phone Number
State
Zip Code
Child’s hobbies
Person responsible for child's account:
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I have insurance that may cover part or all of my child's dental treatment.
Insurance Company
Group #
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Medicaid #
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Private Pay
Household Net Income: ________________ How many people in household: ______________
Health History
Is your child seeing a physician now?
Physician's Name
List medications child is taking now
Why?
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List any medication allergies _________________________________________________________
Does your child have or has you child ever had any of the following conditions:
Yes No
Yes No
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Allergies
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Hyperactive/ADHD/ADD
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Anemia
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Infectious Diseases
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Asthma
Herpes TB HIV Hepatitis
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Bleeding Problems
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Jaundice
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Cancer
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Kidney Disease
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Cerebral Palsy
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Liver Disease
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Cleft Lip & Palate
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Pregnant
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Delayed Speech Development
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Psychiatric Problems
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Developmentally Delayed
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Rheumatic Fever
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Diabetes
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Seizures
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Emotional Disturbance
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Sickle Cell Anemia
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Fainting Spells
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Other
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Hearing Loss/Impairment
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Heart Condition/Murmur
Has your child ever been hospitalized?
When?
Why?
Dental History
Yes
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No
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Has your child ever had a toothache?
Has your child ever received a blow to his/her teeth?
Does brushing cause his/her gums to bleed?
Does your child take a baby bottle at bedtime?
Any unhappy dental experience?
Do you assist child with tooth brushing?
Why is your child here today? (main dental concern)
When was your child's last dental appointment?
Behavior Profile
How do you think your child has reacted to past medical or dental procedures?
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very good
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moderately good
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moderately poor
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very poor
How do you expect your child to react in the dental chair?
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very good
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moderately good
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moderately poor
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very poor
Does your child think there is anything wrong with his/her teeth such as a chipped tooth, decayed
tooth, gumboil?
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Yes ( )
No
Whom may we thank for referring you to our office
x
Signature of Parent or Guardian
Date