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• Beaverton: (503) 644-4749 • Hillsboro: (503) 642-1535 • Portland (Cedar Hills): (971) 713-3899

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Hi5 Dental is proud to announce a new location in Beaverton, OR!

We have moved Pediatric dentistry services to our Beaverton practice and our Cedar Hills practice will provide Orthodontic services!

Medical History Form


Although dentistry deals with primarily teeth and its surrounding structures, oral cavity is a part of the entire body. Health problems that your child may have, or medications that your child may be taking could have an important interation with dentistry your child may receive. Thank you for answering the following questions thoroughly.


The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

Contact Information

Patient First Name: *

Patient Middle Name:

Patient Last Name: *


Date of birth: *



Patient Gender: *

  Male   Female  


Medical History

Name of Child's Physician?:

Child Physician's Phone Number:


Any problems/complications durning pregnancy/delivery? If yes, please explain: *

Does your child have any health problems? If yes, please explain: *

Has your child been diagnosed with any medical conditions? If yes, please explain: *

Has your child ever been hospitalized? If yes, please explain (For & When): *

Has you child ever had surgery? If yes, please explain (For & When): *

Is your child taking any medication? If yes, please list: *

Is your child allergic to any medications/food/latex? If yes, please list: *

Are your child's immunizations up to date?: *


Check any of the following for which the patient has been treated:

AIDS/HIV Positive





Blood Problems



Cerebral Palsy


Down Syndrome

Ear Infection

Emotional Problems

Endocrine Problems

Epilepsy Seizures

Eye Problems

Hearing Problems

Heart Problems

Hepatitis A/B/C

Liver/Kidney Disease


Prolonged Bleeding

Rheumatic Fever

Speech Problems



Thyroid Disease


Dental History

Main reason for today's visit?:

How often are the child's teeth brushed?

1x/day 2x/day every other day not regularly  

How often are the child's teeth being flossed?

1x/day every other day 1x/week not regularly  

Who does the brushing and flossing?

parent child half/half none  


Fluoride Use?:

Rx by MD/DMD in H2O toothpaste rinse none  

When was your child weaned off nursing/bottle?

6 mos 12 mos 24 mos still use  

Does your child have any oral habits?

thumb/finger binky mouth breather grinding  


History of Dental Trauma? If yes, please explain:

How would you rate mother's oral health?

Excellent Good Fair Poor I don't know  

How would you rate father's oral health?

Excellent Good Fair Poor I don't know  

How would you rate your child's candy consumption? (candy, juice, etc)

low average high  


Is there any additional medical/dental information you may want the dentists at Hi5 Dental to know?


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Our Doctors:
Hai Pham, DMD
Jenette Intrachat, DDS
Grace Shao-Chiu Chen, DMD, MS
Jessica Irwin, DMD

TOP DENTIST, Portland Monthly

Dr. Pham was featured in Portland Monthly, chosen
as one of the Top Dentists, Pediatric Dentistry, 2011, 2012, 2013, 2014, 2015.

Proud Member
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Hospital Privileges
Dr. Pham has hospital privileges at:


Hi5 Dental
Dentistry for Kids
3075 SE Century Blvd Ste 109
Hillsboro, OR 97123
Phone: (503) 642-1535
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Hi5 Dental
2375 SW Cedar Hills Blvd,
, OR 97225
Phone: (971) 713-3899
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Hi5 Dental
Pediatric Dentistry
14671 SW Millikan Way
Beaverton, OR 97006
Phone: (503) 644-4749
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Office Hours

Monday - Thursday: 8am to 5pm
Friday: 8am to 12pm

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Hai Pham DMD - Hi5 Dentistry for Kids | | (503) 642-1535
2375 SW Century Blvd, Hillsboro, Or 97225



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Hai Pham DMD - Hi5 Dentistry for Kids, 2375 SW Century Blvd, Hillsboro, Or 97225 / (503) 642-1535 / / 5/22/2024 / Key Phrases: Board Certified Pediatric Dentist Beaverton OR /