New Patient Form for Children

Name (Last):

(First/Given):

(MI):

Preferred Name:

Gender:
MaleFemale

Status:
MarriedSingleOtherChild

Birth Date:

Email Address:

Telephone:

Preferred Contact Method:
CellEmailText

Address (Unit#/Street Name):

City/Prov.:

Postal Code:

Emergency Contact Information

Name:

Phone #:

Relationship:

Who referred you to our practice:
SignWebsiteSocial MediaRadioOther (Please specify)
 

Primary Insurance

Employer:

Name of Insured:

DOB (Insured/Plan Holder) (DD/MM/YYYY):

Relationship to Insured:
SelfSpouseChildOther

Plan Name (Insurance Company):

Group/Plan/Policy#:

ID/Certificate#:

Secondary Insurance:

Employer:

Name of Insured:

DOB (Insured/Plan Holder) (DD/MM/YYYY):

Relationship to Insured:
SelfSpouseChildOther

Plan Name (Insurance Company):

Group/Plan/Policy#:

ID/Certificate#:

Medical History (Please check all that apply):

Drug Allergy:
CodeineIbuprofenPenicillinSulfaErythromycinLatex

Skin:
AcneEczemaPsoriasisMelanoma

Muscular:
Muscular dystrophy

Cardiovascular/Heart:
AnginaAnemiaBypass surgeryHeart attackHeart murmurLow blood pressureHigh blood pressureHeart diseaseBlood disorderPacemakerRheumatic feverValve replacement

Respiratory:
SinusTuberculosisAsthmaLung

Bone:
ArthritisOsteoporosisJoint Replacement

Urinary:
Kidney disease

Digestive:
UlcersLiver diseaseHepatitis (specify Type)Acid Reflux

Endocrine:
Thyroid diseaseDiabetes (specify Type)

Nervous:
Neurological disorderStrokeMental HealthMultiple sclerosisHead injuryEpilepsySeizuresCreturzfeldt-Jakob (prion)Anxiety

Marijuana Use:
RecreationalMedicinalInhalationEdibleVape Use

Immunodeficiency:
STIHerpes (specify Type)Super bugs MRSA/VREHIV/AIDS

Autoimmune Disease:
LupusRheumatoid Arthritis

Other:
Recreational drug useTobacco useVape UseWeight fluctuationChemotherapySleep apneaInsomniaSteroid useRadiation TreatmentCeliac

Weight:

Height:

Have you been hospitalized or undergone surgery in the past 2-3 years:
YesNo

Have you taken antibiotic premedication for dental treatment before?
YesNo

Are you pregnant?
YesNo

Due Date:

Are you breast feeding?
YesNo

Are you currently attempting to conceive?
YesNo

When was your last medical examination?

Are you presently under the care of a physician?
YesNo
 

Please provide the name and phone number of your primary physician

Dental History:

What is the reason for your dental visit today?

Please check all that apply
Frequent HeadachesJaw/TMJ problemsClenching/GrindingOrthodontics/BracesSleep apneaReceding gumsDry mouth

Do you currently have the following?
Oral device/ApplianceDentureNight guardSports guardOrthodontic retainerOther (specify)
 

How often do you brush your teeth?
Once/dayTwice/day3 Times/daySeldomNo

How often do you floss your teeth?
Once/dayWeeklySeldomNo

Do you have dental anxiety?
YesNo

When was your last visit to the dentist?

What was done at your last dental office?
ExaminationHygieneDental treatment

Authorization to the best of my knowledge, all of the preceding information is true and correct. If there is a change to my health, I am going to inform the office at my next dental apointment without fail. I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or incorrect information has the potential of being hazardous to my health. I understand that I am financially responsible for any outsanding balance for services provided that are not fully covered by insurance.

Signature:

Date:

Relationship to Patient:
SelfParent/Guardian

Children and Adolescents:

Sleep, Breathing & Habit Questionnaire:

Patient's Name

Age

DOB(DD/MM/YYYY):

Please indicate if your child experiences or has experienced any of the symptoms below by using this scale to measure the severity of these symptoms.

0 - No Occurrence
1 - Occurs Rarely
2 - Occurs 2 to 4 times per week
3 - Occurs 5 to 7 times per week

Snoring

Interrupted snoring where breathing stops

Labored, difficult or loud breathing at night

Gasping for air while sleeping

Mouth breathes while sleeping

Mouth breathes during the day

Restless sleep

Grinds teeth while sleeping

Talks in sleep

Excessive sweating while sleeping

Wakes up at night

Wets the bed (currently)

History of bedwetting

Feels sleepy and/or irritable during the day

Headaches

Frequent throat infections

Seasonal allergies

Ear infections or history of ear infections

Short attention span

Trouble Focusing

Difficulty listening/often interrupts

Hyperactive

ADD/ADHD

Sensory issues

Struggles in math at school

Struggles in reading in school

* Speech Issues

Avoidance behavior towards food or certain types of food