Children's Form

PATIENT INFORMATION
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your cooperation in filling out the data on the confidential questionnaire is essential in aiding us to perform the highest standard of dental care. All information is strictly confidential and will remain with this office.
Child's full name
Last
First
Middle
Prefers to be called (if different)
Age
Gender
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Home Phone
Format: (000) 000-0000.
Address
Street
City
Province
Postal Code
Favourite Sport/Hobby
Family Physician
Phone Number
Format: (000) 000-0000.
Previous Dentist
City / Address
Whom may we thank for referring you
In case of emergency notify
Name
Relationship
Address
Telephone
Format: (000) 000-0000.
Person Responsible for Account
Name
Home Phone
Format: (000) 000-0000.
Business Phone
Format: (000) 000-0000.
Address
Street
City
Province
Postal Code
Dental Insurance
Name of Insurance Company
Insurance Policy Number
SIN or Certificate Number
Driver's Licence Number
CONFIDENTIAL MEDICAL HISTORY
1. When did your child last visit the physician?
Reason
2.Has your child ever had any serious illness or been in the hospital?
If so, describe
3. Does your child have any known medical, physical or special needs?
If so, describe
4. Has you child ever had any of the following?
Measles
Kidney Disease
Lung Disease
Heart Trouble
Scarlet Fever
Cancer
Epilepsy or Seizures
Fainting Spells
Adenoid Problems
Ear Trouble
Asthma
Mumps
Diabetes
Tuberculosis
Rheumatic Fever
Strep Throat
Operations
Liver Disease
Hepatitis
HIV
AIDS
Shortness of Breath
Hay Fever
Chicken Pox
Gland Trouble
Nervous Disorder
Chest Pain
Tonsillitis
Physical Deformity
Jaundice
Abnormal Blood Pressure
Other
5. If yes to any of the above, please describe
6. Is your child allergic to anything?
If yes, describe
7. Does he or she bruise easily or bleed profusely if cut?
8. Does your child any blood disease?
9. Does your child have any emotional problems?
10. Is your now taking, or has he or she had:
Penicillin
Other Antibiotics
Other Drugs
Local Anaesthesia
General Anaesthesia
11. Has he or she had any unfavourable reaction to these drugs?
12. Is there a history of any inherited disease in the family?
If yes, describe
CONFIDENTIAL DENTAL HISTORY
1. Has your child had previous dental care?
If yes, when was last visit
2. Has he or she ever had an unpleasant experience associated with dental treatment?
If yes, please describe
3. Has your child ever had an accident, injury or surgery about the mouth?
4. Is there family history of
High decay rate
Tooth deformity
Spaced teeth
Missing teeth
Extra Teeth
Crooked Teeth
Cleft lip
Cleft palate
Lip biting
If yes, describe
5. Does your child have any oral habits such as
Thumbsucking
Fingersucking
Lip biting
Nail biting
Mouth breathing
Chewing (i.e. pencils)
Teeth grinding
If yes, describe
6. Has your child ever had orthodontic treatment?
7. How often does your child brush?
Floss?
8. Do you supervise the child while toothbrushing?
9. Has your child ever received oral hygiene or toothbrushing instruction from a dentist or a dental hygienist?
10. Has your child ever received fluoride supplements in the diet or water supply?
11. Has your child ever received a fluoride treatment?
12. Are you interested in learning more about a caries (dental decay) preventative program for your child?
13. If there is any specific problem regarding your child's teeth and oral health which concerns you, or if there is any additional information which you feel may be helpful in our care of your child? Please state:
CONSENT FOR TREATMENT AND OFFICE POLICY
I, the undersigned, acknowledge that I have provided an accurate personal and medical-dental history and to the best of my knowledge, al the preceding answers are true and correct. I wil inform you if there are any changes ni this person's health or medications at future appointments.

You may contact their physician, fi necessary, to discuss any relevant medical information.

I consent to the performing of any dental procedures and x-rays agreed to be necessary or advisable and I will ascsuhmanegeanayn responsibility for fees associated with such procedures. I understand that 48 hours notice must be given fi I need to appointment, otherwise a fee may be charged.
Signature
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DOCTOR
Should be Empty:

PATIENT INFORMATION

Child's full name

Address

In case of emergency notify

Person Responsible for Account

Address

CONFIDENTIAL MEDICAL HISTORY

4. Has you child ever had any of the following?

10. Is your now taking, or has he or she had:

CONFIDENTIAL DENTAL HISTORY

4. Is there family history of

5. Does your child have any oral habits such as

CONSENT FOR TREATMENT AND OFFICE POLICY