Introductory Information
Child's First Name
Child's Last Name *
Middle Initial
Nickname
Gender
Male
Female
Other
If Other
Home Address
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Date of Birth
Age
Child resides with
Relationship to child
Preferred contact phone number (with area code)
Type
Work
Home
Cell
By providing your cell phone number, you consent to being contacted at that number by our practice and our representatives regarding treatment and your account.
Initials
Are there any siblings in the Practice?
Yes
No
Names
Parent Information
Parent 1/Legal Guardian:
Date of Birth
Residence Address (if different from child
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Home Phone # (with area code)
Mobile Phone # (with area code)
Drivers Lic. #
Email Address
Employed by
Position
SSN # (Required if you'd like us to bill your insurance company)
Dental Insurance Carrier
Group #
Address
Phone
Parent 2/Legal Guardian:
Date of Birth
Residence Address (if different from child
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Home Phone # (with area code)
Mobile Phone # (with area code)
Drivers Lic. #
Email Address
Employed by
Position
SSN # (Required if you'd like us to bill your insurance company)
Dental Insurance Carrier
Group #
Address
Phone
Whom may we thank for referring your child to our practice?
Name
Relationship
Whom may we call in case of an emergency?
Name
Relationship
Phone # (with area code)
Pediatrician
Name
Phone # (with area code)
Specialist
Name
Phone # (with area code)
If your child sees any other specialists, please list them with their contact info here
Health History
Child's Name
Date of Birth
Although dental personnel primarily treat the area in and around the mouth, the mouth is a part of your entire body. Health problems that your child may have, or medication that your child may be taking, could have an important affect in the dental treatment your child receives. Thank you for thoroughly answering the following questions.
Medical
Date of last physical exam
Weight
Is your child under medical care?
Yes
No
If so, for what?
Has your child been hospitalized?
Yes
No
If so, for what reason?
Has your child ever had any serious illness or operation?
Yes
No
If so, please explain?
Does your child have any seasonal allergies?
Yes
No
Is your child on a gluten free diet?
Yes
No
Was your child born premature?
Yes
No
If yes, how many weeks?
Does your child bruise easily?
Yes
No
Does he/she have any blood disorders?
Yes
No
Has he/she ever required a blood transfusion?
Yes
No
Has your child had abnormal bleeding associated with any previous surgery, extraction or cuts?
Yes
No
If so, for what?
Does your child urinate more than 6 times a day
Yes
No
Is your child thirsty much of the time?
Yes
No
Is your child wheelchair bound?
Yes
No
Does your child snore?
Yes
No
Is your child undergoing any type of therapy?
Yes
No
If yes, what type?
Occupational
Physical
speech
Other
Does your child have any known allergies or has child ever reacted adversely to any of the following:
Codeine
Yes
No
Latex
Yes
No
Local Anesthetics
Yes
No
Penicillin or other antibiotics
Yes
No
Sulfa Drugs
Yes
No
Sedatives
Yes
No
Tree Nuts
Yes
No
Food
Yes
No
Please specify type(s) of food
Any other?
What adverse reaction occured?
Is your child taking any of the following medications?
Antibiotics or Sulfa Drugs
Yes
No
Asthma Medications
Yes
No
Aspirin
Yes
No
Anticoagulants (blood thinners)
Yes
No
Blood Pressure
Yes
No
Tranquilizers
Yes
No
Cortisone or Steroids
Yes
No
Dilantin or other Anticonvulsant
Yes
No
Insulin, Tolbutamide, Orinase, or similar drug
Yes
No
Iron Supplements
Yes
No
Any other?
List all medications that your child is taking including herbal medicines and vitamins (please specify frequency and dosage)
Has your child had or does your child currently have any of the following?...
ADD/ADHD
Yes
No
Date of diagnosis
AIDS/HIV
Yes
No
Date of diagnosis
Anemia
Yes
No
Date of diagnosis
Arthritis/Inflamatory Rheumatism
Yes
No
Asthma
Yes
No
Date of diagnosis
ASTHMATIC PATIENTS ONLY
Has your child ever been hospitalized due to asthma?
Yes
No
Does your child use an inhaler?
Yes
No
Does he/she have a nebulizer at home?
Yes
No
What triggers their asthmatic episodes?
Stress/Anxiety
Exercise
Enviroment/Change of season
Illness
How frequent are their episodes?
Date of last episode?
Autism
Yes
No
Date of diagnosis
Cancer/Leukemia
Yes
No
Date of diagnosis
Cardiovascular Disease/Heart Trouble (congenital heart disease, heart murmur, ASD, VSD, Stroke, Rheumatic Fever)
Yes
No
If yes, please complete the following...
Per your child's physician have you been advised that antibiotics are required prior to dental procedures?
Yes
No
If Heart Murmur, please indicate:
Innocent
Organic
Not Applicable
If yes, please complete the following:
In Remission
Currently
Does your child currently have his or her blood counts checked on a regular basis?
Yes
No
Has your child undergone chemotherapy?
Yes
No
Cerebral Palsy
Yes
No
Date of diagnosis
Cleft
Lip
Palate
Both
Cystic Fibrosis
Yes
No
Development Delayed
Yes
No
Diabetes
Yes
No
Type
Date of diagnosis
Down Syndrome
Yes
No
Eczema
Yes
No
Epilepsy
Yes
No
Fainting spells/Dizziness
Yes
No
Hearing disability
Yes
No
Wears a hearing aide
Yes
No
If they do wear a hearing aide
Both Ears
Right Ear
Left Ear
Hemophilia
Yes
No
Hepatitus
Yes
No
If yes, what type?
A
B
C
High Blood Pressure
Yes
No
Hives or Skin rash
Yes
No
Hypoglycemia
Yes
No
Irregular heartbeat
Yes
No
Jaundice
Yes
No
If yes, at birth only?
Yes
No
Kidney trouble
Yes
No
Liver disease
Yes
No
Low Blood Pressure
Yes
No
Persistent cough or cough up blood
Yes
No
Psychiatric care
Yes
No
Reflux
Yes
No
Seizures
Yes
No
Date of last seizure
If yes, what type of seizures
Grand Mal
Petit Mal
Febrile
Sickle Cell Disease
Yes
No
Date of diagnosis
Sleep Apnea
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Tuberculosis (TB positive skin test
Yes
No
If yes, results of chect x-ray
Positive
Negative
Tumors or growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Type
Visually Impaired
Yes
No
If yes, they wear:
Glasses
Contacts
Dental
Is this your child's first dental visit?
Yes
No
If not, what is the date of his/her last dental exam?
Does your child have a disability that prevents treatment in a dental office setting?
Yes
No
Has he/she had any serious trouble associated with previous dental treatment?
Yes
No
If so, please explain
Do your child's gums bleed when brushing?
Yes
No
Has he/she ever been treated for any type of gum disease?
Yes
No
Does your child grind or clench his/her teeth?
Yes
No
Has he/she had toothaches or sores in his/her mouth or jaws?
Yes
No
Has he/she had orthodontic treatment (braces)?
Yes
No
If yes, what was the name of their orthodontist?
Have you been satisfied with your child's previous dental care?
Yes
No
If not, please explain
Valid User Check
DISCLOSURE AND CONSENT OF PARENTS
To the best of my knowledge, all of the proceeding answers are true and correct. I understand, if there is any change in my child's health history and/or the medications he/she takes, I will inform the doctor at the next appointment without fail.
Parent's/Legal Guardian Signature
Date
Submit
