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Your First Visit
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Contact
New Patient Child Form
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2021-03-28T14:03:36-07:00
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Patient Name
First
Middle
Last
Preferred Name (Nickname)
Gender
Home Address
Email
City
State
Zip
Cell Phone
Siblings (Ages)
Name of School
Grade Level
Whom may we thank for referring you to our office?
Relationship
Single
Married
Partners
Divorced
Widowed
Name
Name
Relationship
Relationship
Cell Phone
Cell Phone
Email
Email
Occupation
Occupation
Employer
Employer
Does family reside in same household? If no, what percentage in each home:
Checkboxes
Yes
No
Has any other member of the family been a patient at this office? Names:
Checkboxes (copy)
Yes
No
In case of emergency, whom should we contact?
Phone
Person Responsible for Account
Checkboxes
Same as Above
Relationship to Patient
Birthdate
Address
City
State
Zip
Responsible Party Employed by
Insurance Company
State
Subscriber ID
Social Sec No
Group No
Is the patient adopted?
Checkboxes
Yes
No
Is the patient taking any medication?
Checkboxes
Yes
No
Has the patient's physician advised prophylactic antibiotics for dental procedures?
Checkboxes
Yes
No
Is the patient allergic to any medication or nickel/latex?
Checkboxes
Yes
No
Has the patient had their tonsils/adenoids removed? If so what age:
Checkboxes
Yes
No
Does the patient have a history of major illness?
Checkboxes
Yes
No
Has the patient had any major operations?
Checkboxes
Yes
No
Has the patient ever been involved in a serious accident?
Checkboxes
Yes
No
Any medical conditions we have not discussed that you feel we should be aware of?
Checkboxes
Yes
No
Checkboxes
Abnormal Bleeding
Bone Disorders
Heart Problems
Pneumonia
ADHD
Diabetes
Hepatitis/Liver Problems
Radiation/Chemotherapy
Anemia
Dizziness/Fainting
Herpes
Sinus Problems
Arthritis/Rheumatism
Emotional Problems
High Blood Pressure
Thyroid Problems
Asthma
Epilepsy
HIV/AIDS
Tuberculosis
Bisphosphonate Therapy
Gastrointestinal Disorders
Kidney Problems
Tumor or Cancer
Blood Disorders
Hay Fever
Nervous System Disorders
Family Dentist
Date of Last Cleaning
Is the patient currently seeing dental specialists (Periodontist, Oral Surgeon, Endodontist)?
Checkboxes
Yes
No
Has the patient experienced any unfavorable reaction to dentistry?
Checkboxes
Yes
No
Have there been injuries to face, mouth, or teeth?
Checkboxes
Yes
No
Does the patient have pain or clicking when opening/closing the mouth?
Checkboxes
Yes
No
Has the patient's jaw ever locked open or closed?
Checkboxes
Yes
No
Does the patient have speech difficulties?
Checkboxes
Yes
No
Does the patient have difficulty breathing through the nose?
Checkboxes
Yes
No
Has the patient consulted with an orthodontist? If yes, please provide name/date:
Checkboxes
Yes
No
Checkboxes
Bleeding Gums
Cavity Prone
Difficulty Losing Baby Teeth
Missing Teeth
Blisters on Lips/in Mouth
Chewing Difficulties
Extra Teeth
Thumb/Finger Habits
Broken/Chipped Teeth
Clenching/Grinding Teeth
Frequent Headaches
Tongue Habits
What about the teeth/bite would you or your child like to improve?
Checkboxes
Appearance
Cost
Length of Time
Pain
Effectiveness
Other
Signature
Date
Single Line Text
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