Patient Information
Patient's First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Age:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Responsible Party
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Ext:
Cell Phone:
Birthdate:
Social Security Number:
Drivers Lic:
Email:
Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Primary Insurance Information
Do you have dental insurance?
Yes
No
Name of Subscriber:
Relationship to Patient:
Self
Spouse
Child
Other
Subscriber Soc. Sec:
Birthdate:
Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Referral
Whom can we thank for referring you to our office?
Signage
New Resident Gift
Insurance
Mailer
Magazine
Walk-in
Google
Website
Social Media
Yelp
Sibling
Community Event
Referring Dr
Pediatrician
Current Patient
Event or referral's name (if applicable):
Medical History
Physician Name:
Date of Last Physical:
Address:
City:
State:
Zip:
Phone:
*
Yes
No
Is your child currently being treated by a physician for a specific illness or disorder? If so, for what reason?
*
Yes
No
Is your child taking any medications at this time? (please list all drugs, dosages, and reasons below)
*
Yes
No
Has your child experienced any allergies or unusual reactions? (please list any allergies below)
*
Yes
No
Were there any complications before or during birth, prematurity, birth defects, or inherited conditions?
*
Yes
No
Has your child ever been hospitalized? When and for what reason?
*
Yes
No
Has your child ever had any operations? When and for what reasons?
Please select YES if the patient has a history of the following conditions
Accidents or Severe Infections?
Yes
No
ADD/ADHD?
Yes
No
Anemia or Blood Disorder?
Yes
No
Asthma or Lung Problems?
Yes
No
Autism?
Yes
No
Cerebral Palsy?
Yes
No
Congenital Heart Defect/Murmur?
Yes
No
Diabetes?
Yes
No
Gastrointestinal Disorders?
Yes
No
Headaches?
Yes
No
Hemophilia/Abnormal Bleeding?
Yes
No
Intellectual Disability?
Yes
No
Kidney or Bladder Problems?
Yes
No
Leukemia?
Yes
No
Liver Problems or Hepatitis?
Yes
No
Radiation/Chemotherapy?
Yes
No
Seizures/Epilepsy?
Yes
No
Speech or Hearing Disorder?
Yes
No
Tumor or Cancer?
Yes
No
Vision Problem?
Yes
No
*
Yes
No
Does your child's physician recommend antibiotic premedication for your child prior to a dental procedure?
*
Yes
No
Is there any other significant medical history pertaining to your child that the dentist should be aware of?
Provide details here:
Dental History
What is the reason for your child's visit today?
Dental Experience
*
Yes
No
Has your child previously been to a dentist?
If yes, please answer below:
Dentist Name:
Dentist Location:
How long since last dental visit?
How long since last cleaning?
How long since last x-rays?
*
Yes
No
Has your child ever had an unpleasant dental experience?
Describe:
Oral Habits
Has your child ever had any of the following habits?
(please indicate ages when the habit occurred)
*
Yes
No
Use of pacifier?
*
Yes
No
Thumb of finger sucking?
*
Yes
No
Bottle to bed or nap?
*
Yes
No
Tongue Thrusting?
*
Yes
No
Mouth breathing?
*
Yes
No
Teeth Grinding?
Oral Hygiene and Diet
How often are your child's teeth brushed?
*
Yes
No
Does a parent or adult routinely assist with brushing? If so, who and how often?
*
Yes
No
Does your child's toothpaste contain fluoride?
*
Yes
No
Is your tap water at home provided by a community water supply (compared to other sources such as private well water)?
*
Yes
No
Does your child take any additional fluoride supplementation (such as prescription drops or tablets)?
*
Yes
No
Does your child use floss? How often?
*
Yes
No
Does your child use mouthrinse? What kind and how often?
What are your child's favorite snack foods?
What liquids does your child typically consume?
Hisotry of Dental Injuries
*
Yes
No
Has your child ever experienced a dental injury?
Involved teeth/location:
When:
Describe the cause:
Treatment:
Fun Facts
What would you like to see in your dentist?
School/Grade Level
Brothers or Sisters
Favorite Hobby/Sport
Favorite Food
Favorite Animal
Musical Instruments Played
Any other information you would like us to know?
To the best of my knowledge, the questions on this form have been accurately answered. 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 medical status.
Signature of Parent or Guardian
Date