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 :
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Month
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December
Year
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2015
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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 :