Today's Date *

MM

DD

YYYY

Patient's Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Parent or other Emergency Contact *

First Name

Last Name

Subscriber's Name

First Name

Last Name

Subscriber's Birthday

MM

DD

YYYY

Any problems with growth & development, birth defects, syndromes or inherited conditions?

Yes

Any problems with growth & development, birth defects, syndromes or inherited conditions?

Yes

Heart problems (including congenital heart defects/disease, heart murmur, irregular heart beat, or high blood pressure)

Yes

Heart problems (including congenital heart defects/disease, heart murmur, irregular heart beat or high blood pressure

Yes

Asthma or breathing problems

Yes

Bladder or kidney problems

Yes

Jaundice, hepatitis or liver problems

Yes

Gastroesophageal/acid reflux or stomach problems

Yes

Developmental disorder, learning problems/delays, autism, cerebral palsy, ADD/ADHD

Yes

Epilepsy, convulsions/seizures

Yes

Diabetes, thyroid or other endocrine problems

Yes

Hemophilia, bleeding disorders or taking anticoagulation medications

Yes

Cancer or other malignancies

Yes

History of problems with sedation and/or anesthesia

Yes

Infectious diseases (hepatitis, HIV/AIDS, MRSA, Tuberculosis, endocarditis, recurrent/frequent infections, infections requiring hospitalization or IV antibiotics)

Yes

Do you have any habits?

Mouth breathing

Grinding/clenching

Nail Biting

Any jaw joint problems (clicking, popping, pain)?

Yes

What kind of toothpaste do you use? *

With fluoride

Without fluoride

Not sure

Have you ever had a difficult dental appointment? *

Yes

No