,0 ediaic � nﬁs & Orthodontics Patient Information Child's name: ____________________ Nickname: ______________ Sex: (M) (F) Purpose of visit: ___________________ Conces: ________________ Birthdate: _ ___ _ Name and age of brothers/sisters: Is your child adopted? Y N Child's Interests: _____________________ _ Name of Pet(s): _____________ _ Does your child have any special needs? ___________________ _ Any phobias?_ _______ _ Allergies?--------------------------------------- - - - - - Child's leaing: slow average accelerated Child's school: _____________________________ _ Who may we thank for referring you to us?------------------------------- -- - Health History Child's Pediatrician: ___________ _ Phone number : (�- - �) ____ _ Last Physical: _______ _ Is your child under a physician's care now? Y N If yes, reason: _________________ Immunization up to date? Y N Is your child taking any medications currently (including Bisphosphonates and over the counter)? Y N If yes, please list in the back Is your child allergic to any medication? Y N If yes, please list: ___________________________ _ Any history of hospitalization or surgery: (if yes, when) ______________________________ _ Has your child had an history or ever been diagnosed with any of the following? Anemia Allergy/Hay fever Chemotherapy Pneumonia Asthma Arthritis/ Rheumatism Chicken Pox Polio Autism Diabetes Fainting Hemophilia Hepatitis HIV+/AIDS Measles Mumps Cancer, type Dental History Artificial heart valve Artificial joint/limb Epilepsy/seizure Birth defects Bleeding Disorder Brain injury Brain surgery Cerebral Palsy Chronic sinusitis Cleﬅ lip/palate Eye problems Growth problem Heart murmur Kidney problems Liver problems Mental retardation Other Pregnancy Rheumatic fever Scarlet fever Scoliosis Shunt Tetanus Tuberculosis Venereal disease Attention Deficit Disorder Behavior/Leaming Disabilities Bone/Joint/orthopedic problem Digestive disturbances Hearing loss/aids/implants Heart problem/surgery High/low blood pressure Hormonal disturbances Malignant hyperthermia ooping cough Is this your child's first dental visit? Y N If no, previous dentist: _ ________ _ Phone number: (_) _______ _ Date of last visit: _ ___ _ How was his/her experience? _________________ Were any x-rays taken? Y N Child's attitude towards the dentist or dental care: ------------------------- -------- Has your child had any injuries to teeth, mouth, or head? Y N If yes, please describe: __________________ _ Has your child done any of the following (past or present)? Please check: D thumb/finger-sucking D pacifier D nail biting D lip sucking D mouth-breathing D snoring D teeth grinding D nursing D bottle-feeding Is your water fluoridated? Y N Does your child take fluoride supplements? Y N Does your child use fluoridated toothpaste? Y N How often does your child brush his/her teeth?_ ___ With adult supervision? Y N How often does your child floss?_ ___ _ How may we help to make this visit a positive experience for your child? ________________ _______ _ For families with reverse osmosis filtration or in an unfluoridated area, are you interested in a fluoride supplement? Y N Peds HxForm

,0 liediafric Patient J})enfistry Information Orthodontics...& Orthodontics Patient Information ... Any history of hospitalization or surgery: (if yes, when) _ ___

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,0 liediafric � J})enfistry

& Orthodontics

Patient

Information

Child's name: ____________________ Nickname: ______________ Sex: (M) (F)

Purpose of visit: ___________________ Concerns: ________________ Birthdate: _ _ _ _ _

Name and age of brothers/sisters: Is your child adopted? Y N

Child's Interests: ______________________ __ Name of Pet(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _

Does your child have any special needs? _______________ _ _ _ _ _ __ Any phobias? _ _ _ _ _ _ _ _ _

Allergies?---------------------------------------- - - - - --

Child's learning: slow average accelerated Child's school: _____________________________ _

Who may we thank for referring you to us?-------------------------------- - - --

Health History

Child's Pediatrician: ____________ __ Phone number : (�- -�) _ _ _ _ __ Last Physical: _ _ _ _ _ _ _ _

Is your child under a physician's care now? Y N If yes, reason: _________________ Immunization up to date? Y N

Is your child taking any medications currently (including Bisphosphonates and over the counter)? Y N If yes, please list in the back

Is your child allergic to any medication? Y N If yes, please list: ____________________________

Any history of hospitalization or surgery: (if yes, when) ______________________________ _

Has your child had an history or ever been diagnosed with any of the following? Anemia Allergy/Hay fever Chemotherapy Pneumonia Asthma Arthritis/ Rheumatism Chicken Pox Polio Autism Diabetes Fainting Hemophilia Hepatitis HIV+/AIDS Measles Mumps Cancer, type

Dental History

Artificial heart valve Artificial joint/limb Epilepsy/seizure Birth defects Bleeding Disorder Brain injury Brain surgery Cerebral Palsy

Chronic sinusitis Cleft lip/palate Eye problems Growth problem Heart murmur Kidney problems Liver problems Mental retardation Other

Pregnancy Rheumatic fever Scarlet fever Scoliosis Shunt Tetanus Tuberculosis Venereal disease

Attention Deficit Disorder Behavior/Leaming Disabilities Bone/Joint/orthopedic problem Digestive disturbances Hearing loss/aids/implants Heart problem/surgery High/low blood pressure Hormonal disturbances Malignant hyperthermia Whooping cough

Is this your child's first dental visit? Y N If no, previous dentist: ___________ Phone number: (_) _ _ _ _ _ _ _ _

Date of last visit: _ _ _ _ __ How was his/her experience? __________________ Were any x-rays taken? Y N

Child's attitude towards the dentist or dental care: ------------------------- -- - - - - - - --

Has your child had any injuries to teeth, mouth, or head? Y N If yes, please describe: __________________ _

Has your child done any of the following (past or present)? Please check:

D thumb/finger-sucking D pacifier D nail biting D lip sucking D mouth-breathing D snoring D teeth grinding D nursing D bottle-feeding

Is your water fluoridated? Y N Does your child take fluoride supplements? Y N Does your child use fluoridated toothpaste? Y N

How often does your child brush his/her teeth? _ _ _ _ With adult supervision? Y N How often does your child floss? _ _ _ _ _

How may we help to make this visit a positive experience for your child? _________________ __ _ _ _ _ _ _ _

For families with reverse osmosis filtration or in an unfluoridated area, are you interested in a fluoride supplement? Y N

Peds HxForm