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Health Status Update Report

Refresh a paediatric patient record between one visit and the next: address changes, insurance changes, medication, allergies and orthodontic treatment. Dental and paediatric practices send it ahead of each appointment. It closes with the signature of the parent or guardian.

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Patient name

First Name

Last Name

Date of birth

Parent or guardian name

First Name

Last Name

Phone number

Has your home address changed?

Yes No

New address

Street Address

City

State / Province

ZIP / Postal Code

Has your health insurance changed?

Yes No

Details of the new insurance

Are the patient's parents legally married (for insurance purposes)?

Yes No Prefer not to say

Has your child seen a doctor since the last visit?

Yes No

Tell us about that visit

Has your child's medical history changed since the last visit?

Yes No

Has your child had any injury to the face, head, neck, mouth or teeth in the past six months?

Yes No

Is your child up to date with vaccinations?

Yes No

Is your child taking any medication at the moment?

Yes No

Does your child have allergies (food, seasonal, medication, latex)?

Yes No

Does your home use mains water or well water?

City water supply Well water Both Not sure

Does your child take a fluoride supplement?

Yes No

Does your child drink fluoridated water?

Yes No

Is your child under the care of an orthodontist?

Yes No

Does your child wear braces or another fixed dental appliance?

Yes No

Has your child finished orthodontic treatment?

Yes No

Has your child had their wisdom teeth removed?

Yes No

Tick whatever applies to your child

Thumb sucking Teeth grinding Mouth breathing Nail biting Uses a pacifier None of these

Is there any other dental or medical concern?

Yes No

Describe those dental or medical concerns

Is there anything you would like to discuss privately with the clinician?

Yes No

As the signatory, I agree with the following statements

The information given is accurate I will report any change I consent to the treatment indicated

Date

Signature

Sign here

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