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3 ilhf#r$f HEA eil ffirge l"*lvr& EN rj s? ugl gfjtlf g hhei Lr*{y \R DE f-$tlg f rl n hr'r lrf Wha would you like us o do for your child oday? -Jr 1* Former Denis Address Denisl's Phone - Dae of las denal Dae of las x-rays n r+ Has your child ever experienced (} (} How ofen does your child brush? Floss? join? D Y D a mouh or chin injury? r Y r N Does your child experience pain or discomfor in he jaw Ffn Does your child have speech problems? hl Has your child ever experienced an adverse reacion during \c U Child's habis affecing he mouh or N or in conjuncion wih a medical or denal procedure? r eeh: D Thumb sucking r Nail biing r Y r N..,,.i'r* :r:riiiir 0her..- UX Oher informaion abou your child's denal healh or previous reamen r*5 & -Js U HJ F L$ *ff s U lhr ** -JF lsyourchildcurrenlyunderphysiciancare?dyanlfyes,describe u Hasyourchildeverhadabloodransfusion?DYrNlfyes,giveapproximaedaes \D F :,,.+:r:ri J Has your child ever aken Fen-Phen/Redux? Check ( :rir-sir'...i!i:s.$::;:. i-!...:.: / DY r operaions? r Y r N Y- qrr f.": \d ry nn DN r Y D N ry DN ry DN ry DN oydn OY Coughupblood Diabees Epilepsy Faining Foodallergies Headaches ry DN AY D N BY ON Hearproblems Shorness of breah Sinus problems Liverdisease rybn ryrn DYBN ryrn Maerial allergies (laex, wool, meal, chemicals) rybn ry rn Tonsilliis Respiraorydisease 0her Hemophilia/ Abnormal bleeding lmmunizaionscurren Kidneydiseaseor malf uncion BY DN BY rn Hearing lmpairmen Describe fff.r N ) yes or no wheher your child has had any of he following: ADS/HVPosiive ry QN Anemia Ashma D Y r N Aopic (allergy prone) ry DN Blooddisease Cancer ChickenPox u Y D N Convulsions/Epilepsy o Y l N Cough, persisen ry a N DYD N Rheumaic/ScarleJever Lis medicaions your child is aking, if any: ::l.if'" i.:j.r.si: Has your child had any serious illnesses or LreF = lii:* Physician's lf yes, describe,-\. # iii\ffi! ffi Child's Physician Dae of las visi fi F ds 'es,i:::ii;jir:i,,rx fl\l ^.,F \ Skin rash Spina Bifida Thyroid disease or malf uncion Tuberculosis Describe Lis drug allergies, if any: LJ F ds l*ffi lh* '',: have reviewed he informaion 0n his quesionnaire, and i is accurae o he bes of my knowledge. undersand ha his informaion will be used by he denis o help deermine appropriae and healhful denal reamen. lf here is any change in my child's medical saus, will inform he denis. auhorize he insurance company indicaed on his form o pay o he denis all insurance benefis oherwise payable rendered. auhorize he use of his signaure on all insurance submissions. o me for services rrses auhorize he denis o release all informaion necessary o secure he paymen of benefis. undersand ha am financially responsible for all charges wheher or no paid by insurance. Dae Signaure Paynen is due in full a ime ol rcamen, unless prior arrangemens have been SmarPracice ':...i=i".r g_* Sf;"rlw5 HSnaf# JSf'{?TAH 5Wf?T AHJ l\q ls5 ''l*; #80-783R1 E J Uffi dhj OilJ* J5l Jfl{*fi

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