Child Patient Information

Patient Information

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Parent / Guardian Information

Parents' Marital Status

Single Married Divorced Widowed Significant Other

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Emergency Contact

Emergency Contact Name (other than parent)

Phone Number

Relation to child

Address

City

State

Zip

Person(s) OK to release appointment or medically related information to concerning child.

Relation

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Insurance Information

Primary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

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Dental History

How did you hear about our Practice?

Ad Internet Family/Friend Physician Other

Name of person referring (if applicable)

Have your child's tonsils or adenoids been removed?

Yes No

Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Does your child have any missing or extra permanent teeth?

Yes No

Has your child ever had an injury to (select all that apply)

Teeth Mouth Chin

Does your child have speech problems?

Yes No

If so, explain

Does your child currently or has your child ever had any of the following habits (check all that apply)?

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

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Medical History

Is your child currently being treated by a physician?

Yes No

Reason

Physician

Deductible (if known)

Phone

Does your child have any allergies/sensitivities to medications or latex?

Yes No

If yes, please list allergies:

Is your child currently taking any prescription or over-the-counter medications?

Yes No

Please list, with dosage:

Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes No

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?

Yes No

If yes, give approximate dates

Is your child pregnant?

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

Check if your child has or has ever had any of the following

Anemia Arthritis, Rheumatism Artificial Heart Valves

Artificial Joints Asthma Back Problems

Blood Disease Cancer Chemical Dependency

Chemotherapy Circulatory Problems Cortisone Treatments

Cough, Persistent Coughing Blood Diabetes

Epilepsy Fainting Glaucoma

Headaches Heart Murmur Heart Problems

Hemophilia Hepatitis High Blood Pressure

HIV/AIDS Jaw Pain Kidney Disease

Liver Disease Mitral Valve Prolapse Pacemaker

Radiation Treatment Respiratory Disease Rheumatic Fever

Scarlet Fever Shortness of Breath Skin Rash

Stroke Swelling of Feet or Ankles Thyroid Problems

Tobacco Habit Tonsillitis Tuberculosis

Ulcer Venereal Disease

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Authorization

Security Measure

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