Patient History (child under 18 years old)

1. Tell Us About Your Child

Today's Date

Child's Last Name

First Name

Middle

Nick Name

Child's Birthdate

Child's Age

School

Grade

Child's Home #

SS #

Email address

Child's Home Address

APT / CONDO #

City

State

Zip

2. Who Is Accompanying The Child Today?

Name

Relation

Do you have legal custody of this child?

Yes No

Whom may we Thank for referring you?

Other family members seen by us

Previous / Present Dentist

Last Visit Date

3. Mother's Information

Step Mother

Guardian

Name

Birthdate

Home #

Cell #

Employer

Work #

SS #

DL #

4. Person Responsible For Account

Name

Relation

Billing Address

City

State

Zip

Home #

DL #

Employer

Work #

Ext

SS #

Who is responsible for making appointment?

Name

Work #

Ext

Home #

5. Primary Dental Insurance

Add Secondary Insurance?

6. Why did you bring the child to the dentist today?

Has the child ever had a serious / difficult problem associated with previous dental work?

Yes No

Is the child's water fluoridated?

Yes No

Is the child taking fluoridated supplements?

Yes No

Has the child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?

Yes No

Does the child brush his / her teeth daily?

Yes No

Floss his / her teeth daily?

Yes No

Child's Physician

Phone #

Date of Last Visit

Please describe the child's current physical health

Good

Fair

Poor

Has your child ever taken Phen-Fen?

Yes

(Also known as Redux or Pondimin) If so, when?

Please list all drugs that the child is currently taking

Please list all drugs/materials that the child is allergic to

Latex?

Yes

Metal / Nickel?

Yes

Plastic?

Yes

7. Has the child ever had any of the following medial problems?

If other, Please specify

Please discuss any serious medical problems that the child has had

8. Does / did the child have any of the following habits?

Lips Sucking / Biting

Nail Biting

Nursing Bottle Habits

Thumb / Finger Sucking

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Neighbor or Relative not living with you.

Name

Phone

Address

City

State

Zip

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the parent / guardian & patient named herein.

Initials

Date

Doctor's Comments

Medical History Update

Add new row

Your information will be encrypted.