NEW PATIENT FORM FOR CHILDREN AND TEENS

NAME

DATE OF BIRTH (YYYY-MM-DD)

NAME OF PARENT OF GUARDIAN FILLING OUT FORM

MEDICAL INFORMATION

IS YOUR CHILD PRESENTLY UNDER THE CARE OF A PHYSICIAN FOR ANYTHING OTHER THAN REGULAR CARE?(required)

YES

IF SO, FOR WHAT?

ARE YOUR CHILD’S IMMUNIZATIONS CURRENT?(required)

YES

PLEASE LIST ANY ALLERGIES (E.G. MEDICATION, LATEX)

PLEASE LIST ANY MEDICATIONS OR SUPPLEMENTS

HAS YOUR CHILD EVER BEEN HOSPITALIZED?(required)

YES

IF SO, PLEASE EXPLAIN

HAS YOUR CHILD HAD GENERAL ANAESTHETIC?(required)

YES

IF SO, REASON

DOES YOUR CHILD HAVE OR HAD ANY HISTORY OF THE FOLLOWING

HEART MURMUR(required)

YES

FAINTING OR DIZZINESS(required)

YES

SEIZURES/EPILEPSY(required)

YES

HORMONE ISSUES(required)

YES

DIABETES/ENDOCRINE DISORDERS(required)

YES

CANCER, DIAGNOSIS & TREATMENT(required)

YES

GENETIC DISORDER(required)

YES

HEART DISEASE OR RHEUMATIC FEVER(required)

YES

ASTHMA OR LUNG DISEASE(required)

YES

BLEEDING PROBLEMS OR BRUISING(required)

YES

KIDNEY DISEASE(required)

YES

STOMACH ISSUES (E.G. IBS, CELIAC DISEASE)(required)

YES

PSYCHOLOGICAL ISSUES(required)

YES

FAMILY PHYSICIAN OR OTHER HEALTH CARE PROVIDER NAME

PHONE

DENTAL INFORMATION

IS THIS THE FIRST VISIT TO THE DENTIST?(required)

YES

IS THERE A SPECIFIC DENTAL PROBLEM? PLEASE DESCRIBE

IS THIS AN EMERGENCY VISIT?(required)

YES

ANY INJURY TO HEAD, MOUTH, OR TEETH?(required)

YES

ANY MOUTH HABITS? (E.G. THUMBSUCKING, NAIL BITER)(required)

YES

ANY HISTORY OF

CAVITIES

TOOTHACHES

PAIN

BROKEN TEETH

INFECTIONS

MISSING TEETH

WHEN AND HOW OFTEN DOES YOUR CHILD BRUSH?

WITH ASSISTANCE?(required)

YES

WHAT TYPE OF WATER DOES YOUR CHILD DRINK?

TAP

FILTERED

BOTTLED WATER

HAS YOUR CHILD HAD DENTAL FREEZING (LOCAL ANAESTHETIC)?(required)

YES

HAS YOUR CHILD HAD ANY UNHAPPY EXPERIENCES WITH DENTAL CARE?(required)

YES

WHAT’S YOUR CHILD’S ATTITUDE TOWARD TODAY’S VISIT?

PERSONAL INFORMATION

CHILD’S FAVOURITE TOY, HOBBY, TV SHOW, SPORT

NAME OF SCHOOL

ANY BEHAVIOURAL OR LEARNING ISSUES (E.G. AUTISM, ADHD) PLEASE DESCRIBE

HOW WOULD YOU EXPECT YOUR CHILD TO BEHAVE IN OUR OFFICE?

WOULD YOU DESCRIBE YOUR CHILD AS

SHY

APPREHENSIVE

OUTGOING

DOES YOUR CHILD HAVE EXCESSIVE WORRIES? ANXIOUS OR DEPRESSED?

IS THERE SOMETHING PARTICULAR YOU WOULD LIKE US TO KNOW ABOUT YOUR CHILD OR FAMILY?

PATIENT CONSENT

I, THE UNDERSIGNED, CERTIFY THAT ALL OF THE ABOVE MEDICAL AND DENTAL INFORMATION IS TRUE TO MY KNOWLEDGE AND I HAVE NOT OMITTED ANY PERTINENT INFORMATION. I, THE UNDERSIGNED, CONSENT TO THE PERFORMING OF DENTAL AND ORAL SURGERY PROCEDURES AGREED TO BE NECESSARY OF ADVISABLE, INCLUDING THE USE OF LOCAL ANAESTHETIC AS INDICATED, AND I WILL ASSUME RESPONSIBILITY FOR FEES ASSOCIATED WITH THESE PROCEDURES. PATIENT(PARENT, GUARDIAN) NAM

Date (YYYY-MM-DD)

NEW PATIENT FORM FOR CHILDREN AND TEENS