Children's Form

PATIENT INFORMATION
DATE

MonthDayYear
Date
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

MaleFemale
Date of Birth

DayMonthYear
Date
Home Phone
Address
Street
City
Province
Postal Code
Favourite Sport/Hobby
Family Physician
Phone Number
Previous Dentist
City / Address
Whom may we thank for referring you
In case of emergency notify
Name
Relationship
Address
Telephone
Person Responsible for Account
Name
Home Phone
Business Phone
Address
Street
City
Province
Postal Code
Dental Insurance

YesNo
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?

YesNo
If so, describe
3. Does your child have any known medical, physical or special needs?

YesNo
If so, describe
4. Has you child ever had any of the following?
Measles

YesNo
Kidney Disease

YesNo
Lung Disease

YesNo
Heart Trouble

YesNo
Scarlet Fever

YesNo
Cancer

YesNo
Epilepsy or Seizures

YesNo
Fainting Spells

YesNo
Adenoid Problems

YesNo
Ear Trouble

YesNo
Asthma

YesNo
Mumps

YesNo
Diabetes

YesNo
Tuberculosis

YesNo
Rheumatic Fever

YesNo
Strep Throat

YesNo
Operations

YesNo
Liver Disease

YesNo
Hepatitis

YesNo
HIV

YesNo
AIDS

YesNo
Shortness of Breath

YesNo
Hay Fever

YesNo
Chicken Pox

YesNo
Gland Trouble

YesNo
Nervous Disorder

YesNo
Chest Pain

YesNo
Tonsillitis

YesNo
Physical Deformity

YesNo
Jaundice

YesNo
Abnormal Blood Pressure

YesNo
Other

YesNo
5. If yes to any of the above, please describe
6. Is your child allergic to anything?

YesNo
If yes, describe
7. Does he or she bruise easily or bleed profusely if cut?

YesNo
8. Does your child any blood disease?

YesNo
9. Does your child have any emotional problems?

YesNo
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?

YesNo
12. Is there a history of any inherited disease in the family?

YesNo
If yes, describe
CONFIDENTIAL DENTAL HISTORY
1. Has your child had previous dental care?

YesNo
If yes, when was last visit
2. Has he or she ever had an unpleasant experience associated with dental treatment?

YesNo
If yes, please describe
3. Has your child ever had an accident, injury or surgery about the mouth?

YesNo
4. Is there family history of
High decay rate

YesNo
Tooth deformity

YesNo
Spaced teeth

YesNo
Missing teeth

YesNo
Extra Teeth

YesNo
Crooked Teeth

YesNo
Cleft lip

YesNo
Cleft palate

YesNo
Lip biting

YesNo
If yes, describe
5. Does your child have any oral habits such as
Thumbsucking

YesNo
Fingersucking

YesNo
Lip biting

YesNo
Nail biting

YesNo
Mouth breathing

YesNo
Chewing (i.e. pencils)

YesNo
Teeth grinding

YesNo
If yes, describe
6. Has your child ever had orthodontic treatment?

YesNo
7. How often does your child brush?
Floss?
8. Do you supervise the child while toothbrushing?

YesNo
9. Has your child ever received oral hygiene or toothbrushing instruction from a dentist or a dental hygienist?

YesNo
10. Has your child ever received fluoride supplements in the diet or water supply?

YesNo
11. Has your child ever received a fluoride treatment?

YesNo
12. Are you interested in learning more about a caries (dental decay) preventative program for your child?

YesNo
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

Clear
DATE

MonthDayYear
Date
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