Welcome, Tell Us About Your Child PEDIATRIC DENTISTRY Today’s Date: ________________________ Child’s Name: ____________________________________________ Child’s Birthdate: ___________________ Child’s Age: ________________________  Male  Female Social Security #: ________________________________ Nickname: ___________________________________________________ School: ____________________________________ Grade: ______________ Hobbies: ____________________________________________________ Who does your child live with: ____________________________ Is your child adopted?  Yes  No Phone: _____________________________________________ Email: ____________________________________________________________________ Child’s Home Address: ____________________________________________________________________________________________________________ Parents Information Mother Name: ____________________________________________________________________________________________________ Social Security#: ___________________________________ Drivers License #: ________________________________________ Birthday: ___________________ Home Phone: ____________________________ Work Phone: ________________________ Employer: ________________________________________ Father Name: ____________________________________________________________________________________________________ Social Security#: ___________________________________ Drivers License #: ________________________________________ Birthday: ___________________ Home Phone: ____________________________ Work Phone: ________________________ Employer: ________________________________________ Length of Employment: ___________________________________ Length of Employment: ___________________________________ If not the natural parent(s), are you the child’s legal guardian?  Yes  No Emergency Information Name: ____________________________________________________ Relationship to Patient: _______________________________________________ Phone #: ___________________________ Alternate Phone #: __________________________ Alternate Phone #: _____________________________ Insurance Information Primary Insurance Dental Coverage  Yes  No Insurance Co. Name: ______________________________ Phone #: ______________________ Group # (plan, local, or policy #): ________________________ Insurance Co. Address: ___________________________________________________________________________________________________________ Insured’s Name: ____________________________________________________ Relationship to Patient: _______________________________________ Secondary Insurance Dental Coverage  Yes  No Insurance Co. Name: ______________________________ Phone #: ______________________ Group # (plan, local, or policy #): ________________________ Insurance Co. Address: ___________________________________________________________________________________________________________ Insured’s Name: ____________________________________________________ Relationship to Patient: _______________________________________ How did you hear about us? Friend or Family (Please provide name): _____________________________  Our Website Reffering Dentist (Please provide name): _____________________________ Other: (specify) ________________________________________ Our Staff (Please provide name): ____________________________________  Phone Book  Direct Mail Dental History Previous/ Present Dentist: _________________________________ Dentist Phone #: ____________________ Last visit date: _____________________ Why did you bring the child to see the dentist today? Has the child ever taken any diet pills such as Phen-Fen?  Yes  No Is the child’s water fluoridated?  Yes  No (Also known as Redux or Pondimin) If so, when? _________________ Is the child taking fluoridated supplements?  Yes  No Is the child currently in pain? Has the child ever had any pain/tenderness in in his/her jaw joint (TMJ/TMD)?  Yes  No Does the child brush his/her teeth daily?  Yes  No Does the child floss his/her teeth daily?  Yes  No  Yes  No Does the child require antibiotics before dental treatment?  Yes  No Has the child ever had a serious/difficult problem associated with previous dental work?  Yes  No Child’s Physician: _________________________________________ Physician’s Phone #: ____________________ Last visit date: __________________ Is the child currently under the care of a physician?  Yes  No Please describe the child’s current physical health:  Good  Fair  Poor Please list any drugs that the child is currently taking: __________________________________________________________________________________ Please list all drugs that the child is allergic to: ________________________________________________________________________________________ Allergic to Latex  Yes  No Allergic to Metals  Yes  No Allergic to Nickel  Yes  No Allergic to Plastic  Yes  No Allergic to Dyes  Yes  No Medical History Has the child experienced any of the following medical problems? Abnormal Bleeding/ Hemophilia  Yes  No ADD/ADHD  Yes  No AIDS/HIV+  Yes  No Anemia  Yes  No Any Hospital Stays/ Operations?  Yes  No Artificial Bones/ Joints/Valves  Yes  No Asthma  Yes  No Cancer  Yes  No Chicken Pox  Yes  No Congenital Heart Defect Handicaps/ Disabilities  Yes  No Hearing Impairment  Yes  No  Yes  No Heart Murmur  Yes  No Convulsions Depression/  Yes  No Hepatitis  Yes  No Mood Disorder  Yes  No Diabetes  Yes  No Epilepsy  Yes  No Exposed to HIV, but Negative  Yes  No Are the child’s immunizations current?  Yes  No High Blood Pressure  Yes  No Hives  Yes  No Kidney Problems  Yes  No Liver Problems  Yes  No Low Blood Pressure  Yes  No Lupus  Yes  No Measles  Yes  No Mitral Valve Prolapse  Yes  No Mononucleosis  Yes  No Prosthetics  Yes  No Rheumatic Fever  Yes  No Scarlet Fever  Yes  No Skin Rash  Yes  No Tuberculosis (TB)  Yes  No Is there anything you would like to discuss with the Doctor in Private?  Yes  No Please discuss any serious medical problems the child experiences/ed: ______________________________________________________________________________________________________________________________ I affirm that the information I have given 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 child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need. Signature of Parent or Guardian: ____________________________________________________________ Date: _______________________________ Office Use Only I have verbally reviewed the medical/dental information above with the parent/guardian & patient named herein. Signature of Dentist: ____________________________________________________________ Date: ____________________________________ Dentist’s Comments: ________________________________________________________________________________________________________