NEW PATIENT FORM FOR CHILDREN AND TEENS NINJA FORM

NEW PATIENT FORM FOR CHILDREN AND TEENS
Fields marked with an * are required

NEW PATIENT FORM FOR CHILDREN AND TEENS
DATE *
DATE OF BIRTH *

MEDICAL INFORMATION
IS YOUR CHILD PRESENTLY UNDER THE CARE OF A PHYSICIAN FOR ANYTHING OTHER THAN REGULAR CARE? *
ARE YOUR CHILD’S IMMUNIZATIONS CURRENT? *
HAS YOUR CHILD BEEN VACCINATED FOR COVID-19? *
HAS YOUR CHILD EVER BEEN HOSPITALIZED? *
HAS YOUR CHILD HAD GENERAL ANAESTHETIC? *

DOES YOUR CHILD HAVE OR HAD ANY HISTORY OF THE FOLLOWING
HEART MURMUR *
HEART DISEASE OR RHEUMATIC FEVER *
FAINTING OR DIZZINESS *
ASTHMA OR LUNG DISEASE *
SEIZURES/EPILEPSY *
BLEEDING PROBLEMS OR BRUISING *
HORMONE ISSUES *
KIDNEY DISEASE *
DIABETES/ENDOCRINE DISORDERS *
STOMACH ISSUES (E.G. IBS, CELIAC DISEASE) PSYCHOLOGICAL THERAPY *
THYROID DISEASE *

DENTAL INFORMATION
IS THIS THE FIRST VISIT TO THE DENTIST? *
IS THIS AN EMERGENCY VISIT? *
ANY MOUTH HABITS? (E.G. THUMBSUCKING, NAIL BITER) *
ANY INJURY TO HEAD, MOUTH, OR TEETH? *
ANY HISTORY OF *
WITH ASSISTANCE? *
WHAT TYPE OF WATER DOES YOUR CHILD DRINK? *
HAS YOUR CHILD HAD ANY UNHAPPY EXPERIENCES WITH DENTAL CARE? *
HAS YOUR CHILD HAD DENTAL FREEZING (LOCAL ANAESTHETIC)? *

PERSONAL INFORMATION
WOULD YOU DESCRIBE YOUR CHILD AS *

PATIENT CONSENT
Date *

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