Child Health History

* - required information
If information not available please enter "None" or "Unknown"
 
Your Child
Today's Date: 12/21/2024
Child's Name:
* Last:
* First:
Nickname:
Sex: Male Female
Birthdate:
Age:
SS#/SIN:
School:
Grade:
Child's Home Address:
City:
State/Prov.:
Zip/P.C.:
* Phone:

Mother
Step Mother Guardian
Name:
Home Phone:
Work Phone:
Cell Phone:
SS#/SIN:
Employer:
Occupation:
DL #:

Father
Step Father Guardian
Name:
Home Phone:
Work Phone:
Cell Phone:
SS#/SIN:
Employer:
Occupation:
DL #:

Parent's Marital Status: Single Married Divorced Widowed Separated

Responsible Party
Name:
Relation:
Address:
SS#/SIN:
DL #:
Email:

Who is responsible for making appointments?
Name:
Home Phone:
Work Phone:
Ext:
Cell Phone:
Best time to call (Time):
(Days):

* Whom may we Thank for referring you?

Primary Dental Insurance
Insured's Name:
Relationship:
Birthdate:
SS#/SIN:
Employer:
Date Emp.:
Occupation:
Ins. Company:
Group #:
Emp. #:
Ins. Company Address:
Deductible:
Amount already used:
Max. annual benefit:
Orthodontic Coverage: Yes No

Additional Insurance
Insured's Name:
Relationship:
Birthdate:
SS#/SIN:
Employer:
Date Emp.:
Occupation:
Ins. Company:
Group #:
Emp. #:
Ins. Company Address:
Deductible:
Amount already used:
Max. annual benefit:
Orthodontic Coverage: Yes No

Health History
Has your child had difficulty with previous visits?:
Does your child have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
Has your chld ever taken Fen-Phen/Redux?: Yes No

Has your child ever had any of the following:
Asthma
Cancer
Hepatitis
HIV/AIDS
Hemophilia
Diabetes
Allergies
 Rheumatic Fever
Congenital Heart Defect
Handicaps/Disabilities
Convulsions/Epilepsy
Tuberculosis
Abnormal Bleeding
Heart Murmur

Please explain any medical problems that your child has:

Child's Habits
How often does your child brush?
Floss his / her teeth daily?
Date of last dental visit:
Previous Dentist:
Child's Physician:
Phone #:
Child's Birthdate:
Is your child's water fluoridated? Yes No
Does your child take fluoride supplements? Yes No

Does your child:
Suck thumb/finger Yes No
Suck/Bite lips Yes No
Bite/Chew nails Yes No
Chew hard objects (Pencils, etc.) Yes No
Grind Teeth Yes No
Clench jaws Yes No

Authorization and Release
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

9350 Waukegan Road
Morton Grove, IL 60053
847.470.0850
nscdh@smilesforyou.com
North Shore Center of Dental Health Kids Dentist Park Ridge
©2024 North Shore Center of Dental Health
9350 Waukegan Road, Morton Grove, IL, 60053 | Phone: 847.470.0850 | E-mail: nscdh@smilesforyou.com
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