Plaistow Pediatric Dentistry & Orthodontics

Today's Date

PATIENT
Child's First & Last Name: Date of Birth:      M: F:
Preferred Name: School Grade:
Address: Home Phone:
City, State, ZIP: Cell Phone(s):

PARENTS/LEGAL GUARDIANS
Mother's Name/
Legal Guardian:		 Relationship to Patient
(If Guardian)
Address: Occupation:
Employer:
Email: Bus. Phone:

Father's Name/
Legal Guardian:		 Relationship to Patient
(If Guardian)
Address: Occupation:
Bus. Name:
Bus. Phone:

Child's Physician: Telephone:
Street and City: State and Zip:
Family Dentist: Confirm appointments via email/text message? Y: N:
Who may we thank for referring you?

DENTAL INSURANCE INFORMATION

Insurance Co., Name, Address, Phone:
Policy &/or Group #:
Subscriber's Name: Subscriber's ID#:
Subscriber's Employer: Subscriber's DOB:

PARENT RESPONSIBILITIES

I understand that I am responsible to pay for services rendered to any child at the time of service, unless other, arrangements have been made.

Electronic Signature of Parent/Responsible Party:

Siblings:

MEDICAL HISTORY

1. Were there any difficulties during pregnancy, delivery, or the first year of life?
If so, please explain:
 Y: N:
2. Nursing/bottle/sippy cup/pacifier past or present
If so, please explain:
 Y: N:
3. Is a physician treating your child presently for a specific illness?
 Y: N:
4. Is your child taking any medications at this time?
Drug               Dose               Frequency               Reason




 Y: N:
5. Has your child taken any unusual medications in the past and if so please explain?
 Y: N:
6. Has your child had any allergic or unusual reactions to medications or food?
 Y: N:
7. Has your child ever been hospitalized or had any operations? If so, when and for what reason.
 Y: N:
8. Is your child up to date on all of his/her immunizations? Y: N:
9. Does your child have any history of any of the following conditions? Check if yes.
ADD or PDD
AIDS or HIV
Anemia
Asthma
Autism
Bleeding Disorders
 Cerebral Palsy
Cystic Fibrosis
Diabetes
Down Syndrome
Emotional Problems
Hearing Problems
 Heart Murmur/Defect
Kidney Disease
Latex Allergy
Learning Problems
Sensory Issues
Liver Disease 		Rheumatic Fever
Seizures
Sickle Cell Dis.
Speech Problems
Tuberculosis
Vision Problems
Sensory Problems

ADOLESCENT SECTION (13 and older)


Although dental personnel treat the area in and around the mouth, the mouth is part of your entire body. Health conditions or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Is your child taking oral contraception? Y: N:
Is your child pregnant? Y: N:
Does your child use tobacco? Y: N:

DENTAL HISTORY

1. Please check the reason(s) for seeking care at this time.
First dental visit
Accident 		Toothache/Swelling
Appearance of teeth 		Consult
Check up
2. If your child has been to a dentist previously, when was the visit?
Were X-rays taken at that time?

How did your child react? 		Y: N:
3. Does your child take either fluoride drops or tablets? Y: N:
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