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) __________