NEW PATIENT FORM FOR CHILDREN AND TEENS

NAME(required)

DATE OF BIRTH(required)

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 NO

IF SO, FOR WHAT?

ARE YOUR CHILD’S IMMUNIZATIONS CURRENT?(required)

YES NO

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

PLEASE LIST ANY MEDICATIONS OR SUPPLEMENTS(required)

HAS YOUR CHILD EVER BEEN HOSPITALIZED?(required)

YES NO

IF SO, PLEASE EXPLAIN

HAS YOUR CHILD HAD GENERAL ANAESTHETIC?(required)

YES NO

IF SO, REASON

DOES YOUR CHILD HAVE OR HAD ANY HISTORY OF THE FOLLOWING

HEART MURMUR(required)

YES NO

FAINTING OR DIZZINESS(required)

YES NO

SEIZURES/EPILEPSY(required)

YES NO

HORMONE ISSUES(required)

YES NO

DIABETES/ENDOCRINE DISORDERS(required)

YES NO

CANCER, DIAGNOSIS & TREATMENT(required)

YES NO

GENETIC DISORDER(required)

YES NO

HEART DISEASE OR RHEUMATIC FEVER(required)

YES NO

ASTHMA OR LUNG DISEASE(required)

YES NO

BLEEDING PROBLEMS OR BRUISING(required)

YES NO

KIDNEY DISEASE(required)

YES NO

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

YES NO

PSYCHOLOGICAL ISSUES(required)

YES NO

FAMILY PHYSICIAN OR OTHER HEALTH CARE PROVIDER NAME(required)

PHONE(required)

DENTAL INFORMATION

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

YES NO

IS THERE A SPECIFIC DENTAL PROBLEM? PLEASE DESCRIBE(required)

IS THIS AN EMERGENCY VISIT?(required)

YES NO

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

YES NO

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

YES NO

ANY HISTORY OF

CAVITIES

TOOTHACHES

PAIN

BROKEN TEETH

INFECTIONS

MISSING TEETH

WHEN AND HOW OFTEN DOES YOUR CHILD BRUSH?(required)

WITH ASSISTANCE?(required)

YES NO

WHAT TYPE OF WATER DOES YOUR CHILD DRINK?

TAP

FILTERED

BOTTLED WATER

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

YES NO

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

YES NO

WHAT’S YOUR CHILD’S ATTITUDE TOWARD TODAY’S VISIT?(required)

PERSONAL INFORMATION

CHILD’S FAVOURITE TOY, HOBBY, TV SHOW, SPORT(required)

NAME OF SCHOOL(required)

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

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

WOULD YOU DESCRIBE YOUR CHILD AS

SHY

APPREHENSIVE

OUTGOING

DOES YOUR CHILD HAVE EXCESSIVE WORRIES? ANXIOUS OR DEPRESSED?(required)

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

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(required)

Date(required)

NEW PATIENT FORM FOR CHILDREN AND TEENS