HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING CONDITIONS?

IF YES, PLEASE ELABORATE

ABNORMAL BLEEDING

ADDADHD

ALLERGIES TO ANY DRUGS

ALLERGIES TO LATEX PRODUCTS

ANY HOSPITAL STAYS

ANY OPERATIONS

ASTHMA

AUTISM SPECTRUM DISORDER

CANCER

CARDIAC HEART CONDITIONS

CONGENITAL BIRTH DEFECTS

DIABETES

HEARING IMPAIRMENT

HEMOPHILIABLOOD DISORDERS

HEPATITIS

HIV + AIDS

KIDNEYLIVER CONDITIONS

PREGNANCY

REFLUXGI PROBLEMS

RHEUMATICSCARLET FEVER

SEIZURES

TUBERCULOSIS

DEVELOPMENTAL DELAYSDISABILITIES

NONE OF THE ABOVE

HEALTH HISTORY

IS THIS YOUR CHILD’S FIRST VISIT TO THE DENTIST? IF NOT, HOW LONG SINCE THE LAST VISIT?

PREVIOUS DENTIST’S NAME DATE OF LAST DENTAL XRAYS PREVIOUS INJURIES TO THE TEETH, FACE OR MOUTH?

YES NO

WHY DID YOU BRING YOUR CHILD TO THE DENTIST TODAY? IF YES, PLEASE EXPLAIN

DOES YOUR CHILD HAVE ANY OF THE FOLLOWING HABITS?

LIP SUCKING BITING

NURSING BOTTLE HABITS

NAIL BITING

CAVITIES

BLEEDING GUMS

DISCOLORED TEETH

MOUTH TRAUMABROKEN TOOTH

TEETH GRINDING

TOOTHACHE

SENSITIVITY TO HOTCOLD

BAD BREATH

THUMB FINGER SUCKING

PACIFIER USE

TOBACCO USE

DOES YOUR CHILD HAVE ANY CURRENT DENTAL ISSUES?

DOES YOUR CHILD BRUSH HISHER TEETH DAILY?

DOES YOUR CHILD FLOSS HISHER TEETH DAILY?

IF YES, PLEASE EXPLAIN

YES NO

YES NO

YES NO

HAS YOUR CHILD EVER HAD A SERIOUS OR DIFFICULT PROBLEM ASSOCIATED WITH PREVIOUS DENTAL WORK?

DENTAL HISTORY

YES NO

CHILD’S NAME LEGAL NICKNAME TODAY’S DATE

CHILD’S BIRTHDATE CHILD’S AGE CHILD’S FIRST LANGUAGEMALE FEMALE

CHILD’S HOME ADDRESS CITY STATE ZIP CODE

SCHOOL SPECIAL INTERESTS SIBLINGS WE TREAT

TELL US ABOUT YOUR CHILD

SUSAN FALLAHI, DDS - DIPLOMATE, AMERICAN BOARD OF PEDIATRIC DENTISTRY

3715 PRYTANIA STREET, SUITE 380 | NEW ORLEANS, LA 70115 | P (504) 896-7435 F (504) 896-7437

NEW PATIENT FORM

LIST ALL ALLERGIES YOUR CHILD CURRENTLY HAS LIST ALL MEDICATIONS YOUR CHILD IS CURRENTLY TAKING

CHILD’S PHYSICIAN IS YOUR CHILD CURRENTLY UNDER CARE OF A PHYSICIAN?

YOUR CHILD’S CURRENT PHYSICAL HEALTH

GOOD FAIR POORYES NO

NAME RELATIONSHIP DATE OF BIRTH

MARITAL STATUS SOCIAL SECURITY # DRIVERS LICENSE #SINGLE MARRIED DIVORCED WIDOWED

EMPLOYER WORK # CELL # EMAIL ADDRESS

ADDRESS CITY STATE ZIP

IMPORTANT NOTE: THE PARENT OR LEGAL GUARDIAN WHO ACCOMPANIES THE CHILD IS LEGALLY RESPONSIBLE FOR PAYMENT AT THE TIME OF SERVICE.

THE INFORMATION IN THIS SECTION APPLIES TO THE MAIN LEGAL CAREGIVER OF THE CHILDCHILDREN. IS THIS THE PERSON RESPONSIBLE FOR ACCOUNT?

PARENT/LEGAL GUARDIAN’S INFORMATION

YES NO

HOW DID YOU LEARN ABOUT OUR PRACTICE?

NAME RELATIONSHIP DATE OF BIRTH

MARITAL STATUS SOCIAL SECURITY # DRIVERS LICENSE #SINGLE MARRIED DIVORCED WIDOWED

EMPLOYER WORK # CELL # EMAIL ADDRESS

ADDRESS CITY STATE ZIP

IF DIFFERENT FROM ABOVE IS THIS THE PERSON RESPONSIBLE FOR ACCOUNT?SPOUSE OR EMERGENCY CONTACT’S INFORMATION

YES NO

POLICY OWNER’S NAME RELATIONSHIP DATE OF BIRTH

INSURANCE PROVIDER INSURANCE PHONE GROUP #

SOCIAL SECURITY NUMBER EMPLOYER

PRIMARY DENTAL INSURANCE

SIGNATURE OF PARENTGUARDIAN RELATIONSHIP DATE WITNESS

I UNDERSTAND THAT THE INFORMATION I HAVE GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES IN MY CHILD’S MEDICAL STATUS. I AUTHORIZE THE DENTAL STAFF TO PERFORM THE NECESSARY DENTAL SERVICES MY CHILD MAY NEED.

SIGNATURE