Book Your Appointment I. CHILD'S HISTORYChild’s Full Name* Called by* Child’s SS#* Address (if different)* Age* DOB* MM slash DD slash YYYY Place of Birth* Attends what school* Phone #*Child’s Physician or Pediatrician* Phone #*Family Dentist* Phone #*Whom may we thank for referring you?* Date* MM slash DD slash YYYY II. GENERAL INFORMATIONFather* SS#*DOB* MM slash DD slash YYYY Address* City* State* Zip*Phone*Occupation* Employed by* How long?* Employer’s Address* Phone #*Ext.* Mother* SS#*DOB* MM slash DD slash YYYY Address* City* State* Zip*Phone*Occupation* Employed by* How long?* Employer’s Address* Phone #*Ext.* Address* City* State* Zip*Dental Insurance* Insured’s Name* Other dental Insurance* Insured’s Name* Name of nearest relative* Phone #*Relation* In case of emergency (other than parent)* Phone #*Other children in the home* III. MEDICAL HISTORYPlease circle any of the following your CHILD may have experienced:child medical history Allergies Anemia Asthma/Hay Fever Bleeding Disorder Bronchitis child medical history Cerebral Palsy Diabetes Epilepsy Hearing Disorder Heart Disease child medical history Hepatitis Jaundice Kidney/Liver Disease Lung Problems Mental Disorder child medical history Nervous Disorder Rheumatic Fever Seizures Speech Disorder Tonsils/Adenoids Other physical or mental disorder?* Has any immediate family member had any of the above?* Yes No Please describe* Is your child taking any medications at this time?Is your child taking any medications at this time?* Yes No List if any* Has your child had any unfavorable reaction or allergy to any medication such as penicillin, aspirin, or Novocaine?Has your child had any unfavorable reaction or allergy to any medication such as penicillin, aspirin, or Novocaine?* Yes No List if any? Would you consider your child to be in good general health at the present time?* Yes No If no, please explain* How long since your child’s last physical exam?* Has your child ever been hospitalized? (Hospital, dates, details)* IT IS IMPORTANT THAT ALL ITEMS ON FRONT AND BACK BE COMPLETED NEW PAITENT INFORMATIONIV. DENTAL HISTORYDo you want complete dental treatment for your child?Do you want complete dental treatment for your child?* Yes No What is your main concern about your child’s dental health?* Is this your child’s first visit to the dentist?Is this your child’s first visit to the dentist?* Yes No Has your child ever complained about a dental problem, or had any unhappy dental experiences?Has your child ever complained about a dental problem, or had any unhappy dental experiences?* Yes No Please explain* Was your child breast fed?Was your child breast fed?* Yes No Was your child bottle fed?Was your child breast fed?* Yes No Does your child have any of the following habits? Please circle all that apply:Does your child have any of the following habits? Thumb sucking or finger sucking Mouth breathing Does your child have any of the following habits? Nail biting Pacifier sucking Other* Has your child ever broken or bumped a tooth? If so, give dates* How often are your child’s teeth brushed?* How often are your child’s teeth flossed?* Is your child assisted in brushing?Is your child assisted in brushing?* Yes No In flossing?In flossing?* Yes No Has your child received fluoride treatments?Has your child received fluoride treatments?* Yes No Do you have fluoride in the water where you reside?Do you have fluoride in the water where you reside?* Yes No Does your child take daily fluoride drops or tablets?Does your child take daily fluoride drops or tablets?* Yes No Does your child have frequent cold sores or fever blisters?Does your child have frequent cold sores or fever blisters?* Yes No Do you consider your child to be (choose one)Do you consider your child to be (choose one)* Advanced in learning process Progressing normally A slow learner Has your child inherited dental conditions?Has your child inherited dental conditions?* Yes No If so, please describe* How do you expect your child to behave in our office?* Thank you for your help. If there is any information that you feel might be of value to us in the treatment of your child, please add it here* I give my consent to the purposed comprehensive exam, prophy, fluoride, and x-rays when applicable for (Child)Signature*(Parent or Guardian)Date* MM slash DD slash YYYY OTHER THAN YOURSELF, WHO HAS PERMISSION TO MAKE TREATMENT DECISIONS, FINANCIAL ARRANGEMENTS, AND RECEIVE INFORMATION ON THE PATIENT?*PHOTO CONSENTI* ,give permission to use my child* 's photo on Facebook or the website dentistryforyoungpeople.net in our NO CAVITIES photo album, or our TOOTH FAIRY album. These albums were created to recognize and reward our patients. No last names or tags permitted.CAPTCHA Δ
