Patient Information - Child

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 in this office. Childs : First name : Last name : Middle name :   Date of Birth : Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Sex : Choose Male Female     Address : Street : Town : Province : -Please Choose One- Alberta British Columbia Manitoba New Brunswick Newfoundland North West Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code :   Contact Info : Home Phone : Work Phone : Cell Phone : Email Address :   In Case of Emergency, please notify : Name : Relationship : Address : Telephone : Whom may we thank for referring you?

Insurance Information

Name of person responsible for account :
Address :	Street : Town : Province : -Please Choose One- Alberta British Columbia Manitoba New Brunswick Newfoundland North West Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code :
Dental Ins. :	Yes No Name of Company :
Ins. Policy # :	Employee I.D. #
Dental Insurance Subscriber - Name : Date of Birth : Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Yes No	I authorize release to my insurance company plan administrator the information contained in claims submitted electronically.
	Name of Parent / Guardian

Childs History

Nickname :
	Name and ages of any brothers and sisters :
	Are you seeking treatment for any particular reason and/or routine dental care :
	Other Comments :

confidential Medical history

1. When did your child last visit the physician :

Reason :

2. Name of family physician: - Phone :

3. Has your child ever had any serious illness or been in hospital? If so, why?

Yes No - Reason :

4. Does your child have any medical, physical or mental disorders?

Yes No - Details :

5. Has your child ever had any of the following? (please check)

Asthma Diabetes Kidney Disease Operations Lung Disease Liver Disease Heart Trouble Jaundice Scarlet Fever Abnormal Blood Pressure Broken Bones Shortness of Breath Epilepsy Chest Pains Fainting Spells Tuberculosis Adenoids Physical Deformity Ear Trouble Nervous Disorder Rheumatic Fever Other

If yes to any of the above, please describe :

6. Is your child allergic to anything ?

Yes No - Details :

7. Does he/she bruise easily or bleed profusely for a long period of time?

Yes No - Details :

8. Does your child have any blood diseases?

Yes No - Details :

9. Does your child have any emotional problems?

Yes No - Details :

10. Is your child now taking or has he/she ever had :

Penicillin General Anesthesia Local Anesthesia Cortisone Other Antibiotics Other Drugs

11. Has he/she had any unfavourable reaction to these drugs?

12. Any inherited family diseases?

13. Heart disease, murmur, congenital heart defects? Yes No

14. Please list any other conditions that your child has:

Confidential Dental Information

Has your child had previous dental care?
Yes No	When :
Has he/she ever had an unpleasant experience associated with dental treatment?
Yes No	Describe :
Has your child ever had an accident, injury or surgery about the mouth?
Yes No	Describe :
Is there a family history of : (please check)
High Decay Rate Extra Teeth Spaced Teeth Cleft Lip or Palate Tooth Deformity Missing Teeth Crooked Teeth Gum Disease
If Yes, describe :
Does your child have any oral habits such as : (please check)
Thumb Sucking Lip Biting Mouth Breathing Nail Biting Finger Sucking Chewing(e.g. pencils) Teeth Grinding Tongue Thrusting
If Yes, describe :
Has your child ever had orthodontic treatment? : How often does your child brush his/her teeth? : Has your child ever received oral hygiene or tooth brushing instruction from a dentist or dental hygenist? : Has your child ever received fluoride supplements in the diet or water supply? : Yes No Were his/her teeth ever treated with decay-preventing topical fluorides? : Yes No

Additional Information

If there is any specific problem regarding your child's 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 below :

CONSENT FOR TREATMENT

This certifies that I the undersigned, consents to the agreed upon, necessary, or advisable dental procedures.I will assume full responsibility for the fees associated with these procedures.
Signature :
Date :