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Patient Information

Dental History

Yes	No		Is this your child’s first dental visit? *
If no, please list previous Dental Office: *
Yes	No	Unsure	Were any x-rays taken at previous office? * If your child has had any prior radiographs, please transfer all records prior to your child's appointment. Otherwise, out of pocket expenses become patient's responsibility.

New and Existing Patients

Yes	No	Has your child ever had difficulty receiving dental care? *
If yes, please explain *
Yes	No	Have your child’s teeth ever been injured? *
If yes, please explain *

Who brushes your child’s teeth at home? *

How often? *

Yes

No

Is your child using fluoride toothpaste? *

Who flosses your child’s teeth at home? *

How often?

Yes	No	Is your child currently taking/ has your child previously taken a fluoride supplement? *
Yes	No	Does/did your child have any sucking habits (i.e. thumb sucking, pacifier)? *
If yes, please explain *
Yes	No	Does your child go to bed with a bottle or sippy cup? *
If yes, what is the liquid? *
Yes	No	Does your child have a family history of congenitally missing teeth? *

Please check if your child is having problems with any of the following:

Cavities

Toothache

Abscess

Sensitive Teeth

Wisdom Teeth

Mouth Breathing

Trauma

Gum Infection

Color of Teeth

Grinding or Clenching

Jaw Sounds

Crowding

Bad Breath

Other

Other: (please explain):

Medical History

Yes	No		Do you have Primary Care Physician? *
Patient’s Primary Care Physician Date of last exam
Reason *
Yes	No		Are your child’s immunizations up to date? *
Explain:
Yes	No		Is your child presently being treated for any condition? *
If yes, what condition and who is the specialist? *
Yes	No		Is your child receiving any medications or drugs? *
If yes, what are the medications and for what reason? *
Yes	No	Don't know	Has your child ever been hospitalized or had surgery? *
If yes, please explain: *
Yes	No		Does your child have any allergies to food, medications or other? *
List All: *
Yes	No		Does your child have a heart condition/murmur? *
Explain: *

Has your child had or currently have a history of any of the following:

  ADD/ADHD

  HEMOPHILIA

  OTHER

  AIDS/HIV

  IEP @ SCHOOL/504 PLAN

  ANEMIA

  KIDNEY DISEASE

ADOLESCENT ISSUES:

  ANXIETY/DEPRESSION

  LIVER DISEASE

  ALCOHOL USE

  ASTHMA

  MENTAL ILLNESS

  EATING DISORDER

  AUTISM/ASPERGER

  NUTRITIONAL DEFICIENCY

  ORAL INFECTIONS

  BEHAVIORAL/SENSORY ISSUES

  PREMATURE BIRTH

  PIERCED LIP/TONGUE

  BONE/JOINT ISSUES

  RADIATION TREATMENT

  PREGNANCY

  CANCER

  RESPIRATORY ISSUES

  SMOKING/VAPING/CHEWING TOBACCO

  CEREBRAL PALSY

  RHEUMATIC FEVER

  SUBSTANCE ABUSE

  CLEFT LIP/PALATE

  SCOLIOSIS

  DIABETES

  SEIZURES

  DEVELOPMENTAL ISSUES

  SICKLE CELL ANEMIA

  EPILEPSY

  SINUS ISSUES

  EYE/VISION ISSUES

  STOMACH ISSUE /ULCERS

  FAINTING DIZZINESS

  TUBERCULOSIS

  HEARING/SPEECH ISSUES

  TUMORS

Please explain any of the above and provide any other medical information we should know about your child: *