Spinnaker Pediatric Dentistry Health History Form Child's First Name(Required) Last Name(Required) Nickname Sex Date of Birth Month Day Year Age What are your child's interests or hobbies? Is this your child's first time visiting a dentist?Please selectYesNoDate of last visit Month Day Year Dentist's Name Were you satisfied with your child's previous dental treatment?Please selectYesNoPlease explain: Does your community have fluoride added to the water supply?Please selectYesNoI don't knowIs your child receiving a fluoride supplement at this time?Please selectYesNoIs your child currently under a physician's care for an illness or injury?Please selectYesNoPhysician's Name Date of last exam Month Day Year Reason for exam: Has your child ever been diagnosed or treated for any of the following? Heart trouble or heart murmur ADD / ADHD Rheumatic Fever Neurological Disorders Blood transfusions Bleeding Disorders Hepatitis Asthma AIDS / HIV Kidney Problems Liver Problems Diabetes Tuberculosis Does your child have any allergies to foods, medicines, etc.?Please selectYesNoPlease list all allergies:Does your child have a health problem, syndrome, or medical condition not already mentioned?Please selectYesNoPlease explain: Has your child ever been hospitalized or had surgery?Please selectYesNoPlease explain: Is your child currently taking any medications?Please selectYesNoPlease list all medications:Whom may we thank for your referral? I have answered all questions correctly to the best of my knowledge and give permission for Dr. Cooper and his staff to examine, clean the teeth, apply topical fluoride and take x-rays on the above named child. I understand any necessary treatment will first be discussed with me. Name of Parent or Legal GuardianRelationship to patient Email(Required) NameThis field is for validation purposes and should be left unchanged.