New Pa�ent Informa�on
Pa�ent Name ___________________________________________________ Date _______________________ Name child would like to be called _____________________________________________________________________
Birthday ______/______/______ Age________ Sex___ Race/Ethnicity__________ Primary Language______________
Home Phone _________________________ Home Address ________________________________________________
Names and ages of other children in family ______________________________________________________________
School___________________________________________________________________________ Grade ___________
Mother/Guardian#1___________________________________________ E-mail ________________________________
Guardian#1 SS #________________________________________________________ DOB _______ /_______ /_______
Guardian Address__________________________________________________ Guardian#1 Cell # __________________
Guardian Employer_________________________________________________ Phone ___________________________
Father/Guardian#2 _____________________________________________ E-mail _______________________________
Guardian#2 SS # ________________________________________________________ DOB _______ /_______ /_______
Guardian#2 Address ________________________________________________ Guardian#2 Cell # __________________
Guardian#2 Employer_______________________________________________ Phone ___________________________
Who has legal custody of pa�ent? ___________________________________Shared Custody? _____________________
Person responsible for payment of account _______________________________________________________________
Dental Insurance: Yes No If yes, Subscriber’s Name_______________________________________________
Employer _________________________________ Insurance Company ________________________________________
Claims Address _____________________________________________________________________________________
Insurance phone ____________________________ Group No _______________________________________________
Secondary Dental Insurance: Yes No If yes, Subscriber’s Name _______________________________________
Employer _________________________________ Insurance Company ________________________________________
Claims Address _____________________________________________________________________________________
Insurance phone ____________________________ Group No _______________________________________________
Yes No Is your child in good health? Name of child’s physician _______________________________________
Date of last exam ______/______/______
Yes No Has your child ever had a health problem? __________________________________________________
Yes No Had your child ever been hospitalized? Reason(s) and dates_____________________________________
__________________________________________________________________________________________________
Yes No Is your child allergic to anything? __________________________________________________________
Yes No Is your child currently taking any medica�on(s)? Please list medica�on(s) and reason(s) ______________
__________________________________________________________________________________________________
Yes No Were there any problems at birth? ________________________________________________________
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Health History
Please check if your child has been treated for any of the following:
Heart disease/murmur Liver/GI disease Kidney disease Speech/hearing Cerebral palsy Cancer/tumors
Bleeding/transfusions Anemia Rheuma�c fever Seizures Congenital birth defects Recurrent headaches
Asthma Diabetes Hepa��s Cle� lip/palate Personality/social Frequent infec�ons
Blood dyscrasias HIV/AIDS Mental delays Physical delays G-tube Other Problems
Please elaborate on any items checked:
Yes No Does your child see a specialist for any health problems? If yes, please give reason, doctor and doctor’s
phone #:
Do you consider your child to be advanced in the learning process
progressing normally
slow in the learning progress
Was your child breast fed bo�le if so, at what age was this stopped? ____________
Dental Health History
Yes No Has your child ever been to the den�st? Name of child’s den�st ________________________________
Date of exam ______/______/______
Yes No Has your child experienced unfavorable reac�on from previous dental care? If yes, explain ___________
__________________________________________________________________________________________________
Yes No Does your child suck a finger, thumb or pacifier?
Yes No Does your child have pain with chewing, yawning or wide opening?
Yes No Does your child’s jaw make noise and is pain associated with the sound?
Please check if your child is having problem with any of the following:
Cavi�es Trauma Orthodon�cs
Toothache Gum Infec�ons Jaw Sounds
Teeth Sensi�vity Color of Teeth Other
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Fluoride History
Yes No Does your child use a fluoride toothpaste?
Yes No Do you give your child any other form of fluoride? If so, what? _________________________________
Pa�ent Signature ___________________________________ Rela�onship to Pa�ent_____________________(if minor, signature of parent or legal guaradian) (if minor)
Dr. Review (office only) __________