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: CodeineIbuprofenPenicillinSulfaErythromycinLatexSkin: AcneEczemaPsoriasisMelanomaMuscular: Muscular dystrophyCardiovascular/Heart: AnginaAnemiaBypass surgeryHeart attackHeart murmurLow blood pressureHigh blood pressureHeart diseaseBlood disorderPacemakerRheumatic feverValve replacementRespiratory: SinusTuberculosisAsthmaLungBone: ArthritisOsteoporosisJoint ReplacementUrinary: Kidney diseaseDigestive: UlcersLiver diseaseHepatitis (specify Type)Acid RefluxEndocrine: Thyroid diseaseDiabetes (specify Type)Nervous: Neurological disorderStrokeMental HealthMultiple sclerosisHead injuryEpilepsySeizuresCreturzfeldt-Jakob (prion)AnxietyMarijuana Use: RecreationalMedicinalInhalationEdibleVape UseImmunodeficiency: STIHerpes (specify Type)Super bugs MRSA/VREHIV/AIDSAutoimmune Disease: LupusRheumatoid ArthritisOther: Recreational drug useTobacco useVape UseWeight fluctuationChemotherapySleep apneaInsomniaSteroid useRadiation TreatmentCeliacWeight: Height: Have you been hospitalized or undergone surgery in the past 2-3 years: YesNoHave you taken antibiotic premedication for dental treatment before? YesNoAre you pregnant? YesNoDue Date: Are you breast feeding? YesNoAre you currently attempting to conceive? YesNoWhen 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 mouthDo you currently have the following? Oral device/ApplianceDentureNight guardSports guardOrthodontic retainerOther (specify) How often do you brush your teeth? Once/dayTwice/day3 Times/daySeldomNoHow often do you floss your teeth? Once/dayWeeklySeldomNoDo you have dental anxiety? YesNoWhen was your last visit to the dentist? What was done at your last dental office? ExaminationHygieneDental treatmentAuthorization 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 Date 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 weekSnoring 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 Please check all that apply to your child Is it difficult to understand your child's speech?Gets frustrated when people can't understand speech?Difficult to understand over the phone?Speech sounds abnormal?Nasal speech?Sometimes omits consonants?Hoarseness?Uses M, N, NG insetad of P, V, S, Z sounds?Others have difficulty understanding speech?Liquids and/or solids get into nasal area when eating or drinking?