CHILD S INFORMATION PARENTS INFORMATION

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104 E. Olive Ave., Suite 200 Redlands, CA 92373 Phone (909) 798-0604 Fax (909) 798-9765 www.just4kidsdentistry.com WELCOME NEW PATIENT MEDICAL AND DENTAL HISTORY CHILD S INFORMATION Child s Name: Nickname: Date of Birth: Sex: Address: City: State: Zip: School: Grade: Hobbies/Interests Whom may we thank for referring you to our practice: PARENTS INFORMATION Parents Marital Status: q Married q Divorced q Separated q Single Parent 1 Name: Birthdate: Address: City: State: Zip: Home Number Work Number Cell Number Employer: Occupation: Email: Preferred contact method: q Email q Text q Call q Mail Parent 2 Name: Birthdate: Address: City: State: Zip: Home Number Work Number Cell Number Employer: Occupation: Email: Preferred contact method: q Email q Text q Call q Mail DENTAL INSURANCE INFORMATION Primary Insured Name: SSN: DOB: Ins. Company Name: Group Policy No: Ph. # Secondary Insured Name: SSN: DOB: Ins. Company Name: Group Policy No: Ph. # CHILD S MEDICAL HISTORY Child s Physician: Date of last visit: Reason for visit: Name of Practice: Phone #: Are Immunizations Current? q Yes q No Is your child under medical care at present? q Yes q No If Yes, please explain: Has Your Child had any of the following diseases or conditions? Please check off ALL that apply: q ADD/ADHD q CHRONIC SINUS INFECTIONS q HEART DISEASE q RHEUMATIC FEVER q ALLERGIES q CHRONIC EAR INFECTIONS q HEART MURMUR q SICKLE-CELL DIS/TRAIT q ANEMIA q CYSTIC FIBROSIS q HEART DEFECTS q TUBERCULOSIS q ANXIETY/DEPRESSION q SEIZURES/EPILEPSY q HEMOPHILIA q NEUROLOGICAL PROBLEMS q ASTHMA q DEVELOPMENTAL DELAY q KIDNEY PROBLEMS q ORTHOPEDIC PROBLEMS q AUTISM SPECTRUM q DIABETES q LIVER PROBLEMS q EYE PROBLEMS q BLEEDING DISORDER q DOWN SYNDROME q LUNG PROBLEMS q ACID REFLUX q CANCER q HIV/AIDS q PSYCHIATRIC TREATMENT q EMOTIONAL DISTURBANCES q CEREBRAL PALSY q HEPATITIS q SPEECH/HEARING PROBLEMS q ORAL/SENSORY INTEGRATION q CLEFT LIP/PALATE q MENTAL RETARDATION q BIRTH DEFECTS q HIGH BLOOD PRESSURE q LEARNING DISABILITY q PREMATURE BIRTH Does your child have any other diseases, conditions or syndromes not listed above? q Yes q No If Yes, please explain: Is your child allergic to any food or medicine? q Yes q No If Yes, please list: Page 1 of 2

CHILD S MEDICAL HISTORY (Continued) Is your child currently taking any medications? q Yes q No If Yes, please list: Has your child ever been sedated or had General Anesthesia? q Yes q No If Yes, what for? Has your child ever had surgery or been hospitalized? q Yes q No If Yes, please explain: Is your child having any difficulties in school? q Yes q No If Yes, please explain: Is there anything else we should know about your child? q Yes q No If Yes, please explain: Is there anything about your child you would like to discuss in private? q Yes q No DENTAL HISTORY Reasons for today s dental visit (check all that apply): q FIRST EXAMINATION q ROUTINE CHECK-UP q TOOTHACHE OR SWELLING q CAVITIES q APPEARANCE OF TEETH q CROWDING q ACCIDENT/INJURY Other: Has your child been to a dentist previously? q Yes q No When: Where: Were X-Rays taken: q Yes q No q Not sure If Yes, may we contact them to get copies? q Yes q No Does your child have any of the following habits? q THUMB/FINGER SUCKING q MOUTH BREATHING q PACIFIER q SNORING q LIP SUCKING/BITING q GRINDING/CLENCHING q BOTTLE/SIPPY CUP TO SLEEP What source of water does your child drink? q City Water q Bottled Water q Well Water Is your child breast fed or using a bottle/sippy cup? q Yes q No If No, what age did it stop? Child s typical eating pattern: q 2-3 meals/day q eats throughout the day Frequency of tooth brushing? times per day, flossing? times per day Who does the brushing? q Child q Parent/Guardian q Both What type of toothpaste does your child use? q Fluoride q No Fluoride q No Paste How would you describe your child s temperament? (Check ALL that apply) q OUTGOING q SHY q STUBBORN q ANXIOUS q FRIGHTENED q REGULAR KID q CURIOUS q MOODY q FRIENDLY q DEFIANT q ACTIVE q COOPERATIVE Has your child ever experienced any problems or complications due to dental care? q Yes q No If Yes, please explain: CONSENT The information I have given is correct to the best of my knowledge. I understand that it is my responsibility to inform this office of any changes in my child s medical status and insurance benefits. I authorize Just For Kids Pediatric Dentistry to complete a Dental Evaluation, including Examination, X-Rays, Photographs, Cleaning and Fluoride Treatment when necessary as standard of care to properly diagnose and record any and all dental conditions. I authorize my insurance company to pay Just For Kids all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance, including all late payment service charges. This consent is to remain in effect from the date indicated until cancelled in writing. Authorized signature Relationship to Child Date OFFICE USE ONLY SBE Prophylaxis required: q Yes q No Precautions: Summary: Caries Risk Assessment: q Low q Med q Hi Dr signature Date Page 2 of 2

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