Welcomehealth History Form

WelcomeHealth History Form

NOTE: The parent of Guardian who accompanies the child is responsible for payment at the time of service.

1.Tell us About Your Child

Child’s Name______

Last First

Address______

Town______state______

Email______

Goes by:______Male____Female__Siblings that we treat______Child’s birthdate_____/_____/____age___

School______Grade___ Child’s Home#(_____)______

2. Who may we thank for referring you toour office?______

3. Mother’s Information

Name______

DOB______

Employer______

Home phone #______cell______SS#______

4. Father’s Information

Name______DOB______

Employer______

Home#______

SS#______

5. Who is Accompanying the Child Today? Name______Realtionship______

6. Dental Insurance

Insurance Co.Name______

Insurance Co. Address______

Insurance Co. Phone #______

Group # (Plan, Local, or Policy #)______

Realtionship to Patient______

Policy Owner DOB______

SS#______

Policy OwnerEmployer______

7. Dental History

Last Dental Visit______

For What Service______

Name of Previous Dentist______

Has the child had dental problems?______

Does the child brush teeth daily?______

Does the Child floss daily?_____

Is fluoride taken in any form? ___

Injuries to mouth, head, teeth? ______

Any unhappy dental experiences? ______

Any mouth habits-thumbsucking, pacifier, bottle sleeping?______

8. Medical History

Child’s Physician______

Phone #______

Date of last exam______

Is the child under care now____

If so for what reason______-

Is the child taking any medications?______

If yes, what type? ______

Ever been hospitalized? ______

If yes, what type?______

Is there excessive bleeding when cut?______

Allergies______

Has the child had any history or difficulty with any of the following? If yes please check (√)

___Aids/H.I.V.__Cerebral Palsy___Epilepsy___Anemia

__Chicken Pox__Fainting__ADD ___Convulsion __Hearing Prob

___Autism__Diabetes_Heart Prob

___BladderProb__Drug/alcohol abuse_Hepatitis__Cancer

__Kidney Disease_Liver Disease

__LatexAllergy_Mononucleosis __Mumps__Rheumatic Fever

__Sinus Prob__Thyroid Dis

___Tuberculosis___Other

In the event of an emergency, whom should we contact?

Name______Relationship______

Insurance Assignment and Release

I certify that my dependent(s) is covered by insurance with ______and assigned directly to Dr.______

Name of Insurance Co.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above –named doctor may use my child’s health care information and may disclose such information to the above named Insurance Co and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

______

Signature of Parent or GuardianDate

______

Print NameDate

Update

To be completed at later Date

Has there been any change in patient’s health since last appointment ___yes___no

If so please describe______

Is patient taking any new medications___yes___no

If so list______

Date______

Parent Signature______

Date______

Dentist Signature______