New Patient Dental/Health Form

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.

(*) indicates a required field.

1. Tell Us About Your Child

Today's Date *

Child's Full Name *

Nickname

Gender *

Child's Birthdate *

Child's Age

School

Siblings We Treat

Does your child have any special interests that we should be aware of? (Ex: Hobbies, Sports, Pets, Cartoon Characters, Super Heroes etc.)

Child's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Child's Home Number

Do we have a current Financial/Insurance Form on file for this child that has up-to-date billing and insurance information? *
(If not, please visit our website to complete one prior to your child's visit.)
Yes No

2. Dental History

Is this your child's first visit to a dentist? *
Yes No

If no, how long since the last visit to a dentist?

Previous Dentist's Name

Date of Last X-Rays at Previous Dental Visits

Have there been any injuries to the teeth, face or mouth? *
Yes No

If yes, please explain:

Why did you bring your child to the dentist today?

Does your child have any of the following habits?

Lip Sucking / Biting

Nursing / Bottle Habits

Thumb / Finger Sucking

Tongue Thrust and Pacifier Use

Nail Biting

Tobacco Use

Does your child have any current dental issues?

Cavities

Bleeding Gums

Bad Breath

Mouth Trauma/Broken Tooth

Toothache

Discolored Teeth

Teeth Grinding

Sensitivity to Hot/Cold

Has your child ever had a serious or difficult problem associated with previous dental work? *
Yes No

If yes, please explain:

Is your child's water fluoridated?
Yes No

Is your child taking fluoride supplements?
Yes No

Has your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?
Yes No

Does your child brush his/her teeth daily?
Yes No

Does your child floss his/her teeth daily?
Yes No

3. Social History

Child's First Language *

Child's Second Language

4. Health History

Has your child ever had any of the following conditions? *

Abnormal Bleeding

ADD/ADHD

Allergies to Any Drugs

Allergies to Latex Products

Any Hospital Stays

Any Operations

None of the Above

Auto Immune Disease

Asthma

Autism Spectrum Disorder

Cancer

Cardiac (Heart Conditions)

Congenital Birth Defects

Developmental Delays/Disabilities

Diabetes

Hearing Impairment

Hemophilia/Blood Disorders

Hepatitis

HIV + / AIDS

Kidney/Liver Conditions

Pregnancy

Reflux/GI Problems

Rheumatic/Scarlet Fever

Convulsions/Seizure Disorder

Tuberculosis

Is your child up to date on immunizations against childhood disease?
Yes No

If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please explain below.

List all drugs your child is currently taking (or write NONE). *

List all allergies your child currently has (or write NONE). *

Child's Physician *

Phone Number

Is your child currently under the care of a physician? *
Yes No

Describe your child's current physical health. *
Good Fair Poor

5. Signature

I understand that the information I have given is correct to the best of my knowledge and that 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 Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)

Relationship to Patient *

Date *