Medical & Dental History (Child)

A parent or guardian should fill this in. It helps us plan a calm, comfortable first visit for your child.

About your child

Date of birth
Gender

Parents and guardians

The parent or guardian who comes to the appointment with the child is responsible for payment at the time of the visit.

Parent or guardian 1

Add a second parent or guardian?

Parent or guardian 2

If different from parent / guardian 1

Do you have legal custody of this child?

Your child's health

Your answers help us treat your child safely. Everything here stays confidential.

Is your child currently under a doctor's care for a specific health concern?
How would you describe your child's general health?
Does your child have now, or have they ever had, any of the following?
then change any that apply
Abnormal bleeding
Allergy to any medication
Allergy to latex
Hay fever / seasonal allergies
Asthma
Autism spectrum disorder
Sensory processing difference
Speech delay
Developmental delay
Emotional or behavioural concerns
Attention difficulties (e.g. ADHD)
Hearing loss
Physical disability
Cerebral palsy
Down syndrome
Condition present from birth
Seizures / epilepsy
Diabetes
Heart condition or murmur
Hemophilia / blood disorder
Sickle cell disease or trait
Hepatitis
Kidney or liver condition
Rheumatic or scarlet fever
Tuberculosis
Cancer
Hospital stay
Surgery

Dental history

Is this your child's first visit to a dentist?
Were x-rays taken at a previous visit?
Has your child ever injured their teeth, face or mouth?
Has your child had a difficult experience with past dental care?
Does your child...
then change any that apply
Have tooth pain right now?
Have jaw pain or clicking?
Brush every day?
Floss every day?
Suck their thumb or fingers?
Use a soother or bottle?
Suck or bite their lip?
Bite their nails?
How would you describe your child's temperament?

Check all that apply.

Dental insurance

Is your child covered by the Canadian Dental Care Plan (CDCP)?
Is your child covered by another dental plan?

Primary plan

Policy holder date of birth
Is your child covered by a second plan?

Second plan

Policy holder date of birth

Agreement

Please tick each statement to confirm it is true for you

Our office follows the infection prevention and control standards of the Royal College of Dental Surgeons of Ontario.

Sign and submit

Your signature confirms the answers and statements on this form.

Who is signing?
Signature

Signed on

Your answers go straight to our office over an encrypted connection. Questions? Call 226-884-2573.