ADA Children's Health History Form

Use the 2021 edition of the Child’s Dental and Medical Health History Information Form to collect pertinent health information about your pediatric patients before treatment. Clear two-sided layout and simple wording make form completion easy. Includes questions related to dental history, medical health history and vaccination status, and medications and allergies.

An additional Patient Screening Form is now included to assess patients for possible symptoms of COVID-19 in advance of their office visit. The form includes lines for pre-appointment and in-office responses that can be used to evaluate if a deeper discussion with the dentist is needed before treatment.