Enter a Patient Health History


Please enter the following information into the form, and press the “Submit” button at the bottom of the page. This information is transmitted safely and securely protected for your confidentiality.

(*) indicates a required field

Child Information

Male
Female

Parent or Guardian Information

Billing Information (if different than parent information)

Insurance Information

Yes
No

Medical History

Yes
No
Yes
No
Yes
No
None Aspirin Codeine
Environmental Erythromycin Food
Iodine Latex Novocaine
Nitrous Oxide Penicillin Sulfa Drugs
Tetracycline Valium Xylocaine
 
None Heart problems (Murmur etc.) Blood or bleeding disorder Breathing problems (Asthma etc.) Muscular problems Bone or joint problems
Nervous disorder (Seizures, epilepsy) Behavior issues (ADHD etc.) Mental disorder (Autism etc.) Hormone, kidney or liver problem (Diabetes) Digestion problems Cancer
Pregnancy Vision, hearing or speaking problems Surgeries Other
 

Dental History

Yes
No
Yes
No
Currently
Yes
No
Currently
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
None Finger Sucking
Mouth Breathing Teeth Grinding
Lip Sucking Nail Biting
Pacifier Tongue Thrusting
 
Vitamins Water Supply
Tooth Paste Tablets/Drops
Rinse/Gel
 
Yes
No
Outgoing Cooperative Shy
Mellow Anxious Curious
Hyper Stubborn Defiant
Friendly Trusting Moody
Suspicious
 

Parents Medical History

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Nearest Relative

dental information

practice
hours

Monday8:30am - 2:30pm
Tuesday12:30pm - 5:30pm
Wednesday8:00am - 5:00pm
Thursday8:00am - 5:00pm
Friday8:00am - 2:30pm