Male/Femalelastfirstmi

WELCOME

Today’s Date: ______

Child’s Name: ______

Male/FemaleLastFirstMI

Nickname______Birth Date:_____/_____/____

Age: ______Social Security # : _____-______-______

School: ______Grade: ______

Home Address: ______

StreetApt#

______

CityStateZip

PhoneHome: (_____)______

WHO IS ACCOMPANYING THE CHILD TODAY?

Name: ______Relation:______

Do you have legal custody of this child? Yes /No

Whom may we THANK for referring you?______

Previous/Present Dentist? ______

Last visit date: ______

Other family members seen by us: ______

______

Parent’s Marital Status:

Single / Married / Divorced / Widowed / Separated

MOTHER’S INFOStepmother/Guardian

Name______Birth Date:_____/_____/____

Social Security Number: ______

Employer: ______

How long? ______Occupation: ______

Employer’s Address: ______

Street

______

CityStateZip

Phone Home: (_____) ______

Mother’s Cell: (_____) ______

Mother Work: (_____)______Ext. ______

e-mail: ______

FATHERS INFOStepfather/Guardian

Name______Birth Date:_____/_____/____

Social Security Number: ______

Employer: ______

How long? ______Occupation: ______

Employer’s Address: ______

Street

______

CityStateZip

Phone Home: (_____) ______

Father’s Cell: (_____) ______

Father Work: (_____)______Ext. ______

e-mail: ______

The parent or guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved.

PERSON RESPONSIBLE FOR ACCOUNT

(if other than yourself)

Name: ______Relation:______

Phone Home: (_____) ______

Work: (_____) ______

Address: ______

Street

______

CityStateZip

PRIMARY INSURANCE INFORMATION

Dental: Yes / No Medical: Yes / No Orthodontic: Yes / No

Insurance Co. Name: ______

Phone: (____)______

Group # (Plan, Local, or Policy #):______

Insurance Co. Address: ______

Street

______

CityStateZip

Insured’s Name: ______

Insured’s Social Security #: ______

Insured’s Birth Date: _____/_____/_____

Relation: ______

Insured’s Employer: ______

Employer’s Address: ______

Street

______

CityStateZip

SECONDARY INSURANCE INFORMATION

Dental: Yes / No Medical: Yes / No Orthodontic: Yes / No

Insurance Co. Name: ______

Phone: (____)______

Group # (Plan, Local, or Policy #):______

Insurance Co. Address: ______

Street

______

CityStateZip

Insured’s Name: ______

Insured’s Social Security #: ______

Insured’s Birth Date: _____/_____/_____

Relation: ______

Insured’s Employer: ______

Employer’s Address: ______

Street

______

CityStateZip

I affirm that the information I have provided is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical or financial status. I authorize the dental staffto perform the necessary dental services I may need in order to obtain my optimum dental health.

X______

Signature Date

My method of payment today will be cash, check, credit card (MC/VISA/Discover)

Card # ______Exp Date: ______

DENTAL HISTORY

Why did you bring the child to the dentist today? ______

Is the child currently in pain?Yes / No

How would you rate the child’s dental Health?

EXCELLENT GOOD FAIR POOR

Does the child floss daily?Yes / No

My child brushes ______times per day.

Type of bristles on your child’s toothbrush?

HARD MEDIUM SOFT

Does you child use any additional oral health products or devices? Yes / No If yes, please list: ______

Ever experienced problems associated with any previous dental work?Yes / No

Ever experienced pain or discomfort in the jaw?

(TMJ / TMD)Yes / No

Does your child’s gums ever bleed?Yes / No

Any loose teeth?Yes / No

Are any teeth sensitive to heat, cold, sweet foods, candy or biting?Yes / No

Does you child have wisdom teeth?Yes / No

Previous Dentist: ______

Last visit: ______Why did you leave your previous dentist? ______

What did you like most/least about any dentist you have seen?______

Are you happy with your child’s smile?Yes / No

Would you like whiter teeth?Yes / No

MEDICAL HISTORY

Physician’s Name: ______

Address: ______

StreetApt#

______

CityStateZip

Phone #: (_____) ______

Date of last visit: ______

How do you rate your overall physical health?

EXCELLENT GOOD FAIR POOR

Is your child currently under the care of a physician?

Yes / No

Please explain:______

______

Does your child smoke or use tobacco in any other form?

Yes / No

Is your child allergic to any of the following?

Y / NAnestheticsY / NAspirin

Y / NBarbituratesY / NCodeine

Y / NErythromycinY / NFoods

Y / NJewelryY / NLatex

Y / NPenicillinY / NSedatives

Y / NSulfaDrugsY / NOther

Please list: ______

Does your child take any of the following?

Y / NAntibioticsY / NAntidepressants

Y / NAntihistaminesY / NAspirin

Y / N Blood ThinnersY / N Cold Remedies

Y / N CortisoneY / NDiabeticMeds

Y / NHeart MedicineY / NInsulin

Y / N NitroglycerinY / NSteroids

Y / N ThyroidMedsY / NTranquilizers

Y / N Blood Pressure Medications

Y / N Nutrition/Vitamin Supplements

Y / N Recreational/Street Drugs

Is your child taking any other over the counter or prescription medication(s) not listed above? Y / N

Please list: ______
______

Has your child EVER had any of the following?

Y / NAbnormalBleedingY / N Alcohol Abuse

Y / N AnemiaY / NArthritis

Y / N Artificial Joints/ValuesY / NAsthma

Y / N BloodTransfusionY / NCancer

Y / NChemotherapyY / NChickenPox

Y / N ColitisY / N Diabetes

Y / N Difficulty BreathingY / N Drug Abuse

Y / N EmphysemaY / NEpilepsy

Y / N Fainting SpellsY / N Fever Blisters

Y / N GlaucomaY / N Hay Fever

Y / N HeadachesY / N Heart Attack

Y / N Heart DefectY / N Heart Murmur

Y / N HeartSurgeryY / NHemophilia

Y / N HepatitisY / N Herpes

Y / N High Blood PressureY / N HIV+/AIDS

Y / N HospitalizationsY / N Kidney Problem

Y / NLiverDiseaseY / N Lupus

Y / N Low Blood PressureY / N Pacemaker

Y / N Mitral ValveProlapseY / NPersistentCough

Y / N Psychiatric ProblemsY / NRadiationTreatment

Y / N Rheumatic FeverY / N Scarlet Fever

Y / N Sickle Cell DiseaseY / N Seizures

Y / N Sinus ProblemsY / N Shingles

Y / N Thyroid ProblemsY / N Stroke

Y / N TuberculosisY / NTonsillitis

Y / NVenerealDiseaseY / NUlcers

Please list any other medical condition(s) not listed above:

______

______

______

______

______

Does your child have the following habits?

Y / N Lip Sucking/Biting

Y / N Nail Biting

Y / N Nursing Bottle Habits

Y / N Thumb/Finger Sucking

Y / N Clenching/ Grinding

THANK YOU VERY MUCH

Rev 6/16