Health History Form - West Madison - Children's Dental Center of Madison, S.C.

Children's Dental Center of Madison, S.C.

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Fitchburg:
(608) 288-1543

East Madison:
(608) 825-7500

West Madison:
(608) 833-6545

Sun Prairie:
(608) 453-5600

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Dental FAQ
Fitchburg
East Madison
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Sun Prairie
Careers

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Home
First Visit
- Forms
Dental FAQ
Fitchburg
East Madison
West Madison
Sun Prairie
Careers

Home
First Visit
Forms
Dental FAQ
Fitchburg
East Madison
West Madison
Sun Prairie
Careers

New Patient Dental/Health Form

West Madison

Thank you for choosing our office for your child’s dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.

Please fill out the form completely. If a section does not apply to you, please write N/A.

Today's Date:

Child's Full Name:

Nickname:

Gender:

Date of Birth:

Age:

School:

Siblings We Treat:

Does your child have any special interests that we should be aware of? (Ex: Hobbies, Sports, Pets, Cartoon Characters, Super Heroes etc.)

Street Address:

Apt #:

City:

State:

Postal/Zip Code:

Child's Home Number:

Secondary Number:

Email Address:

Is this your child's first visit to a dentist?

Yes No

If no, how long since the last visit to a dentist?

Previous Dentist's Name:

Date of Last X-Rays at Previous Dental Visits:

Have there been any injuries to the teeth, face or mouth?

Yes No

If yes, please explain:

Do you have any concerns regarding your child's oral health?

Does your child have any of the following habits?

Lip Sucking / Biting Bottle Thumb / Finger Sucking Pacifier Use Nail Biting Breastfeeding

Does your child have any current dental issues?

Cavities Bleeding Gums Bad Breath Mouth Trauma/Broken Tooth Toothache Cold Sores/Fever Blisters Teeth Grinding Sensitivity to Hot/Cold

Has your child ever had a serious or difficult problem associated with previous dental work?

Yes No

If yes, please explain:

Is your child's water fluoridated?

Yes No Unknown

Does your child brush his/her teeth daily?

Yes No

Is your child taking fluoride supplements?

Yes No

Does your child floss his/her teeth daily?

Yes No

Has your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?

Yes No Unknown

Has your child ever been diagnosed with any of the following?

ADD/ADHD Allergies to Latex Products Anxiety/Depression Any Hospital Stays Any Operations Asthma Autism Spectrum Disorder Auto Immune Disease Cancer Congenital Heart Disorder Convulsions/Seizure Disorder Developmental Delays/Disabilities Diabetes Hearing Impairment Heart Disease Hemophilia/Blood Disorders Hepatitis High or Low Blood Pressure HIV + / AIDS Kidney/Liver Conditions MTHFR Reflux/GI Problems Rheumatic/Scarlet Fever Shunts None of the Above

If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please explain below.

Is your child up to date on immunizations against childhood disease?

Yes No

List all drugs your child is currently taking (or write NONE):

List all allergies your child currently has (or write NONE):

Child's Physician:

Physician Phone Number:

Is your child currently under the care of a physician?

Yes No

Describe your child's current physical health.

Good Fair Poor

Acceptance

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

By printing my name I am consenting to electronically signing this form.

Relationship to Patient :

Date:

Best Pediatric Dentist Madison

5544 E. Cheryl Pkwy
Fitchburg, WI 53711

(608) 288-1543

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5116 American Family Dr
Madison, WI 53718

(608) 825-7500

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7001 Old Sauk Rd., Ste 200 Madison, WI 53717

(608) 833-6545

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250 N City Station Dr, Sun Prairie, WI 53590

(608) 453-5600

Best Pediatric Dentist Madison

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