Child Patient Information/Medical History

If the child is under 18 years of age, we expect a parent of guardian to remain in the office for the child's entire visit.

Today's Date

Last Name

First Name

Middle Initial

Preference

Home Address

City

State

Zip

Home Phone #

Cell Phone #

Date of Birth

Age

Sex

Marital Status

Family Email Address

Child's School

Parent's Information

Marital Status

The following is regarding the patient's

Mother

Step Mother

Guardian

Name

Birth Date

Address

City

State

Zip

Home Phone #

Work Phone #

Cell Phone #

Social Security #

Employer

Length of Employment

Drivers License #

The following is regarding the patient's

Father

Step Father

Guardian

Name

Birth Date

Address

City

State

Zip

Home Phone #

Work Phone #

Cell Phone #

Social Security #

Employer

Length of Employment

Drivers License #

Person Responsible For Account

Name

Relationship

Billing Address

City

State

Zip

Home Phone #

Work Phone #

Cell Phone #

Social Security #

Employer

Length of Employment

Drivers License #

Who is accompanying the child today?

Name

Relationship

Do you have legal custody of this child?

Yes

Is the child adopted?

Yes

Is the child in a foster home?

Yes

Other siblings seen by us

WHOM MAY WE THANK FOR REFERRING YOU?

Health

Is the child under the care of a physician?

Yes

Explain

Child's Physician

Phone #

Please describe the child's current physical health

Good

Fair

Poor

Are immunizations current?

Yes

Has the child had/experienced any of the following:

Artificial Bones/Joint/Valves

Yes

HIV/AIDS

Yes

Diabetes

Yes

Blood Transfusion

Yes

Congenital Heart Defect

Yes

Heart Murmur

Yes

Heart Surgery

Yes

High/Low Blood Pressure

Yes

Mitral Valve Prolapse

Yes

Hepatitis/Liver Disease/Jaundice

Yes

Rheumatic/Scarlet Fever

Yes

Abnormal Bleeding/Aspirin Use

Yes

Asthma/Tuberculosis

Yes

Cancer

Yes

Chicken Pox

Yes

Convulsions/Epilepsy

Yes

Handicaps/Disabilities

Yes

If yes, please specify

Hearing Impairments

Yes

Hive/Skin Rash

Yes

Kidney Problems

Yes

Lupus

Yes

Measles

Yes

Mononucleosis

Yes

Sickle Cell Anemia/Anemia

Yes

Tonsillitis

Yes

Has the child ever been hospitalized for any reason?

Is the child allergic to any of the following?

Motrin (Ibuprofen)

Yes

Dental Anesthetics

Yes

Codeine

Yes

Clindamycin

Yes

Latex

Yes

Penicillin

Yes

Additional Allergies

Please list all medications that the child is currently taking (prescribed or over the counter)

Does/did your child have any of the following habits?

Clenching on Objects

Yes

Clenching/Grinding Teeth

Yes

Lip Sucking/Biting

Yes

Nursing Bottle Habits

Yes

Speech Problems

Yes

Thumb/Finger Sucking

Yes

Tongue Thrust

Yes

Used Pacifier

Yes

Dental History

Is the child currently in pain?

Yes

Has the child ever had any pain/tenderness in his/her jaw joint?

Yes

Has the child experienced problems with previous dental work?

Yes

Is the child's water fluoridated?

Yes

Is the child taking fluoridated supplements?

Yes

Does the child brush his/her teeth daily?

Yes

If yes, how many times?

Floss his/her teeth daily?

Yes

If yes, how many times?

Previous/Present Dentist

Date of last visit

Why did you leave previous dentist?

What did you like MOST about any dentist you have seen?

What did you like LEAST about any dentist you have seen?

What is the primary reason for today's visit?

I UNDERSTAND THAT THE INFORMATION THAT I HAVE GIVEN TODAY IS CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGE IN MY MEDICAL STATUS.

I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED AND ALSO FOR PAYING ANY CO-PAY AND DEDUCTIBLE THAT MY DENTAL BENEFIT DOES NOT COVER ON THE DATE OF SERVICE.

DUE TO THE INCREASED NUMBER OF BROKEN APPOINTMENTS THERE WILL BE A CHARGE OF $50.00 PER ½ HOUR OF APPOINTMENT TIME BILLED TO YOUR ACCOUNT FOR MISSED APPOINTMENTS WITHOUT 48 HOURS NOTICE. WE WILL TRY TO CONFIRM APPOINTMENTS THE DAY PRIOR TO YOUR SCHEDULED TIME. WHEN YOU MAKE AN APPOINTMENT IT IS YOUR RESPONSIBILITY TO KEEP IT. HOWEVER, IF WE CANNOT REACH YOU OR YOU DO NOT GET THE MESSAGE, THE APPOINTMENT IS STILL YOUR RESPONSIBILITY.

Signature of Patient/Legal Guardian

Date

Relationship

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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