(For Office Use Only)

WELCOME TO OUR DENTAL OFFICE I.D. #

Medical Alert Yes □ No □

Date_____________ 

General Health Questionnaire

The data on this confidential questionnaire is essential in performing the highest standard of pediatric dental care for

Child’s Information
Name:__________________________________________ Birthdate: D____ M_____ Y_____
First Last
Nickname:___________________________ Sex:___ Age: ______ Grade/Daycare:_______
Names and ages of siblings:_____________________________________________________________________
Who is responsible for making appointments?______________________________________________________
Daytime Phone Number to Confirm/Schedule Appointments:__________________________________________

Parent/Guardian Information
Name:_________________________________ Relationship:_____________________________
First Last

Address _______________________________________________________________________
City Province Postal Code

Birthday: D ____ M ____ Y ____ Email: ___________________________________________

Home Phone #: ________________________ Mobile Phone #:__________________________

Work Phone #: ________________________

Name:_________________________________ Relationship:_____________________________
First Last

Address _______________________________________________________________________
City Province Postal Code

Birthday: D ____ M ____ Y ____ Email: ___________________________________________

Home Phone #: ________________________ Mobile Phone #:__________________________

Work Phone #: ________________________

Financial Information
Primary Insurance Policy Holder:________________________________
Ins. Company:____________________________________________________ Tel:( ) ______________

Employer: _______________________________________________________ Ins. Yr.End:_____________

Policy #:__________________ Certificate #:____________________________ ID/SIN #:_______________

For Office Use Only

Max Cov:_________ %Coverage for: __________Basic _________Maj.Restorative _________ Orthodontic

Secondary Insurance Policy Holder:________________________________

Ins. Company:____________________________________________________ Tel:( ) ______________

Employer: _______________________________________________________ Ins. Yr.End:_____________

Policy #:__________________ Certificate #:____________________________ ID/SIN #:_______________

For Office Use Only

Max Cov:_________ %Coverage for: __________Basic _________Maj.Restorative _________ Orthodontic

Copyright © 2017. Dental Works 4 Kids. All Rights Reserved.

 Chief Complaint
What’s the reason for today’s visit? _____________________________________________________________
Is your child having oral/dental pain? ____________________________________________________________
If yes, how long has your child been in pain? ______________________________________________________
If yes, does your child require pain medication? ___________________________________________________

Medical
Does your child have any ALLERGIES (including latex)? ____________________________________________
When did your child last visit the medical physician? Date______________ Reason _______________________
List all medications (including herbal) your child is currently taking: ____________________________________
Has your child ever had any serious illness or been admitted to a hospital? ______________________________
Has your child ever had any surgeries (including dental) under general anesthesia? _______________________
Does your child have any known medical, physical, or psychological disability? ___________________________
Has your child had an unfavorable reaction to any drug or has a history of drug allergies? __________________
Does your child have any allergies (food, seasonal, environmental)? ___________________________________

Has your child ever had any of the following? If yes, please check √ appropriate boxes.
□ Heart Problems/Murmur □ Cerebral Palsy □ Autism □ ADHD □ Asthma
□ Eczema □ Rheumatic/Scarlet Fever □ Liver disease □ Lung Disease
□ Kidney disease □ Mumps or Measles □ Epilepsy/Seizures □ Diabetes
□ Cancer □ Tuberculosis □ Hepatitis □ Blood disorder
□ Bruising □ Prolonged Bleeding □ Malignant Hyperthermia
If so, please describe ________________________________________________________________________
Is there a history of any inherited diseases in the family? ____________________________________________
Please describe any medical problems not listed above: _____________________________________________

Dental
Has your child had previous dental care? _______________________ When? ___________________________
Has he/she ever had an unpleasant experience associated with dental treatment? ________________________
Has your child ever had an accident, injury or surgery involving the mouth? _____________________________
How often does your child brush his/her teeth? ____________________________________________________
How often does your child floss his/her teeth? _____________________________________________________
Who performs the brushing & flossing for the child? ________________________________________________
Does your child use fluoridated toothpaste? ______________________________________________________
Has your child ever received fluoride supplements in the diet or water supply? ___________________________
How often does your child snack during the day? __________________________________________________

Orthodontics
Has your child ever had any orthodontic treatment?
__________________________________________________________

Has your child ever had or has experienced any of the following? If yes, please check √ appropriate boxes.
□ Jaw Joint Problems □ Grinding of Teeth □ Thumb / Finger Sucking
□ Nail Biting □ Headaches □ Restless Sleep
□ Tonsils/Adenoids Removed

Nutrition
Does your child have or has experienced any of the following? If yes, please check √ appropriate boxes.
□ Frequent Dental Caries □ Food Intolerances

Speech
Has your child ever had a speech evaluation or previous speech therapy? _____________________________
Do you feel your child has a speech problem? ___________________________________________________
Does your child have difficulty pronouncing any sounds? ___________________________________________

General Release
I certify that all above information is complete. I consent to the release of medical information from my medical doctor or other health cared provider as is required by
this office. I authorize this office to perform diagnostic procedures required to determine necessary treatment. I understand that it is my responsibility to pay for treatment
for both myself and my dependents and assume all responsibility for fees associated with all procedures. I give my permission for the use of records for the purposes of
professional education and consultation. I understand that 48 hr notice is required to avoid a $75 appointment cancellation fee.

_______________________________________ _______________________________________ ___________________________

Signature □ Parent/Guardian □ Self Print Name Date

Copyright © 2017. Dental Works 4 Kids. All Rights Reserved.