Today's Date
*
MM
DD
YYYY
Patient's Name
*
First Name
Last Name
Nickname
Sex
Birth Sex
Gender
*
Birthday
*
MM
DD
YYYY
Height
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Weight
Last Dental Appointment
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Within 6 months
6 months - 1 year
1 - 3 years
More than 3 years ago
This is my first dental visit
Left last Dentist
Moved
Office was too far
Unhappy with treatment and/or dentist
Office no longer accepts my insurance
Office/equipment was too old
Office no longer in business
Fees were unacceptable
Wait time was too long
This is my first visit to a dentist
Other
Parent or Guardian's Name
*
First Name
Last Name
Relationship to child
*
Parent's DOB
MM
DD
YYYY
Occupation/Employer
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent's Email Address
Mobile Phone
*
(###)
###
####
Home Phone
(###)
###
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Work Phone
(###)
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Additional Parent or Guardian's Name
Any other decision maker that may accompany your child at future appointments
First Name
Last Name
Additional Parent's DOB
MM
DD
YYYY
Relationship to child
Occupation/Employer
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
Mobile Phone
(###)
###
####
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Primary Dental Insurance
Policy #
Name of Insured
First Name
Last Name
Subscriber's Date of Birth
MM
DD
YYYY
Subscriber's SS #
Secondary Dental Insurance
Policy #
Name of Insured
First Name
Last Name
Subscriber's Date of Birth
MM
DD
YYYY
Subscriber's SS #
Date of Most Recent Physical Exam
MM
DD
YYYY
Is your child being treated by a physician at this time?
*
Name/Address/Phone of Primary Physician
*
Name/Address/Phone of Medical Specialist
Cardiologist, Endocrinologist or other specialist if applicable
Is your child taking any medication (prescription, over the counter, vitamin or dietary supplement)?
*
Please list name, dose, frequency and reason:
Has your child ever been hospitalized, had surgery or a significant injury/illness that was treated in the emergency room?
*
If yes, please list date & describe:
Has your child ever had a reaction to or problem with an anesthetic?
*
If yes, please describe:
Has your child ever had a reaction or allergy to an antibiotic, sedative or any other medication?
*
Please list:
Is your child allergic to latex, or anything else such as metals, dyes, or acrylics?
*
Please list:
Is your child up to date on immunizations against childhood diseases?
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Was your child born prematurely?
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If yes, what week?
Any complications before or during birth, prematurity, birth defects, syndromes or inherited conditions?
Any problems with physical growth or development?
Sinusitis, chronic adenoid/tonsil infections
Sleep apnea, snoring, mouth breathing, or excessive gagging
Difficulty chewing and/or swallowing, or aspiration pneumonia
Congenital heart defect/disease, heart murmur, rheumatic fever or rheumatic heart disease
Irregular heart beat or high blood pressure
Asthma, reactive airway disease, wheezing or breathing problems?
Cystic fibrosis
Pneumonia or other serious infections
Frequent exposure to tobacco smoke
Jaundice, hepatitis, or liver problems
Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems
Prolonged diarrhea, unintentional weight loss, concern with weight, or eating disorder
Celiac disease, gluten allergy
Lactose intolerance, food allergies, nutritional deficiency, or dietary restrictions
Bladder or kidney problems
Arthritis, scoliosis, limited use of arm and/or legs, muscle, joint or bone problems
Rash/hives, eczema or other skin problems
Impaired vision, hearing or speech
Developmental disorder, learning problems/delays, or intellectual disability
Cerebral palsy, brain injury, epilepsy, or convulsions/seizures
Autism/autism spectrum disorder
Recurrent headaches/migraines, fainting or dizziness
Hydrocephaly or placement of a brain shunt
Behavioral, emotional, communication or psychiatric problems/treatment
Attention deficit/hyperactivity disorder (ADD/ADHD)
Concerns or history of abuse or neglect
Diabetes, hyperglycemia, or hypoglycemia
Precocious puberty or hormonal problems
Thyroid or pituitary problems
Anemia, sickle cell disease/trait, or other blood disorder
Hemophilia, excessive bleeding, or easy bruising
Transfusions or receiving blood products
Infectious diseases (mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), MRSA, sexually transmitted disease (STD), or HIV/AIDS
Cancer, tumors, other malignancies, chemotherapy, radiation therapy, or bone marrow/organ transplant
History or family history of malignant hyperthermia, or adverse reactions to sedation and/or anesthesia
Is there any other significant medical history pertaining to this child or his/her family that the dentist should be told?
IF YOU ANSWERED YES TO TO ANY OF THE QUESTIONS ABOVE PLEASE PROVIDE DETAILS BELOW:
What is your primary concern about your child's oral health?
*
Reason for your visit
How would you describe your child's oral health?
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How would you describe your oral health?
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Is there a family history of cavities?
*
If yes, check all that apply:
Mouth sores/fever blisters
Bad Breath
Bleeding gums
Cavities/Decayed Teeth
Injury to teeth, mouth and/or jaws
Clenching/grinding
Excessive gagging
Jaw joint problems (clicking, popping or locking)
If yes to any of the above, please describe:
Does your child have any oral habits?
If yes, indicate all that apply:
If so, for how long and is the habit still present?
Does someone help your child brush?
*
What kind of toothpaste does your child use? Check all that apply.
*
What is the primary source of your drinking water at home?
*
How long was your child breast-fed?
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How long was your child bottle fed?
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Does/did your child sleep with a bottle?
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If yes, content of bottle?
Does your child use a no spill training cup (sippy cup)?
*
Is your child on a special or restrictive diet?
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If yes, please describe:
Does your child have a diet high in sugar or starches?
*
If yes, please describe:
Candy or other sweets
*
Snacks between meals
*
Soft drinks, sodas, juices or tea
*
Has your child ever had a difficult dental appointment?
*
If yes, please describe:
Is there anything else we should know before treating your child?
*
Please list any concerns below:
Parent's name and signature, relationship to child and date
To be completed at the office
