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What would you like us to do for your child today?

Former Dentist

Dentisl's Email

Address

Phone

Date of last dental Date of last x-rays

How often does your child brush?

Does your child experience pain or discomfort in the jaw joint? D Y D N

Has your child ever experienced a mouth or chin injury? tr Y tr N

Does your child have speech problems?

Has your child ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? tr Y tr N

Child's habits affecting the mouth or teeth: D Thumb sucking tr Nail biting tr 0ther

Other information about your child's dental health or previous treatment

Floss?

Child's Physician

Physician's Email

Date of last visit Has your child had any serious illnesses or operations? tr Y tr N

lf yes, describe

lsyourchildcurrentlyunderphysiciancare?DYaNlfyes,describeHasyourchildeverhadabloodtransfusion?DYtrNlfyes,giveapproximatedates

Has your child ever taken Fen-Phen/Redux? DY tr N

Check ( / ) yes or no whether your child has had any of the following:

D Y tr N Atopic (allergy prone) tr Y D N Fainting

DY DN AIDS/HIVPositive

trY QN Anemia

DY DN Asthma

trY DN Blooddisease

DY DN Cancer

DY DN ChickenPox

trY nN CoughupbloodDY DN Diabetes

OY DN Epilepsy

trY DN Foodallergies

trY DN Headaches

trY DN Hearing lmpairment

trY DN Hemophilia/Abnormal bleeding

AY D N lmmunizationscurrent

BY ON Kidneydiseaseormalf unction

BY DN Liverdisease

BY trN Material allergies(latex, wool, metal,chemicals)

trY a N Respiratorydisease

D Y D N Rheumatic/ScarletJever

Shortness of breath

Sinus problems

Skin rash

Spina Bifida

Thyroid disease ormalf unction

Tonsillitis

Tuberculosis

0ther

DY DNtrYBNtrYtrNDYBNtrYtrN

trYBNtrY trNDY DNDescribe

u Y D N Convulsions/Epilepsy o Y D N Heartproblems

o Y tl N Cough, persistent Describe

List medications your child is taking, if any: List drug allergies, if any:

I have reviewed the information 0n this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used bythe dentist to help determine appropriate and healthful dental treatment. lf there is any change in my child's medical status, I will inform the dentist.I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for servicesrendered. I authorize the use of this signature on all insurance submissions.I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all chargeswhether or not paid by insurance.

Signature Date

Paynent is due in full at time ol trcatment, unless prior arrangements have been approved.@ SmartPractice #80-783R1

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