Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Date of Birth:
Approx. Weight (lbs)
Gender:
Male
Female
Identify as male
Identify as female
Address:
City:
State:
Zip:
School:
Grade/Year:
Was the child adopted?
No
Yes
If yes, does the child know?
No
Yes
Referral Information:
Referral Source:
Another patient family
Dental office
Social media
School
Siblings are patients
Referral Detail:
Health Information
Pediatrician Name:
Phone Number:
Date of Last Visit:
Birth Information:
Gestation Week:
Birth Weight (lbs):
NICU stay?
Yes
No
If yes, duration?
Breathing tube used?
Yes
No
If yes, duration?
Feeding tube used?
Yes
No
If yes, duration?
Please list ALL medications currently being taken by the patient (with dosages; include non-prescription):
Please list any drug, food, or seasonal allergies that the patient may have:
Please select 'Yes' if the patient currently has or has previously had any of the following conditions. Cannot be blank.
Anemia?
Yes
No
Autism spectrum disorder?
Yes
No
Sensory processing disorder?
Yes
No
Congenital birth defect?
Yes
No
Cystic fibrosis?
Yes
No
Down Syndrome?
Yes
No
Eczema?
Yes
No
Hearing impairment?
Yes
No
Hemophilia or blood disorder?
Yes
No
Hepatitis?
Yes
No
High blood pressure?
Yes
No
HIV/AIDS?
Yes
No
Kidney disease?
Yes
No
Liver or GI issues?
Yes
No
Lupus?
Yes
No
Sickle Cell Anemia?
Yes
No
Sickle Cell trait?
Yes
No
Speech delay?
Yes
No
Visual impairment?
Yes
No
Tonsils or adenoids removed?
Yes
No
Thyroid disorder?
Yes
No
Tuberculosis (TB)?
Yes
No
Date recovered:
If yest to any of the above, please explain:
Asthma?
Yes
No
Reactive airway
RSV
Exercise induced
Environment/weather induced
Has rescue inhaler
Cancer or tumors?
Yes
No
Type/location:
Current or treatment completed?
Cerebral Palsy?
Yes
No
Limited neck mobility
Wheelchair bound
Cleft lip or palate?
Yes
No
Previous surgeries:
Cleft team:
Heart murmur (innocent)?
No
Followed by cardiology
Released by cardiology
Congenital heart defect?
Yes
No
Type:
Previous heart surgeries?
Are antibiotics required prior to dental treatment?
Yes
No
Unsure
Epilepsy/seizure disorder?
Yes
No
History of Febrile Seizure?
Diabetes?
No
Type1
Type2
Previous overnight hospitalizations?
Yes
No
Surgeries not listed previously:
Does your child have a social/personality disorder? If yes, please explain:
Yes
No
Is there anything you want to discuss with the doctor in private?
Yes
No
Please list all specialists that your child sees:
Dental History
Is this your child's first visit?
Yes
No
Previous Dentist:
Last Dental Visit:
X-rays taken?
Yes
No
Previous dental work?
Yes
No
Is your child fearful of the dentist?
Yes
No
Any previous dental or mouth injuries?
Yes
No
Bottle until:
Nursing until:
Pacifier until:
Thumb or finger sucking until:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Nail biting?
Yes
No
Bruxism/grinding?
Yes
No
Snoring?
Yes
No
TMJ pain?
Yes
No
Tongue thrust?
Yes
No
How would you predict your child's behavior to be?
Cooperative
Defiant
Fearful
Unsure
Parent/Guardian Information
Marital Status:
**Unless there is only one parent in the child's life, please provide information for both parents.
Married
Seperated
Divorced
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Mother
Guardian
Birthdate:
Same address as child
Address:
City:
State:
Zip:
Email:
Cell Phone:
Home Phone:
Employer:
Occupation:
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Mother
Guardian
Birthdate:
Same address as child
Address:
City:
State:
Zip:
Email:
Cell Phone:
Home Phone:
Employer:
Occupation:
To the best of my knowledge, all of the above answers are true and correct. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in his/her medical status. I hereby give my consent to treatment for my child named above (of whom I am the parent, legal guardian, or foster parent), to Dr. Longoria, Dr. Chen, and associates.
Parent/Guardian E-Signature: