Forms & Charts For our new patients, please complete the form below Patient Name * First Name Last Name Email * Please provide name and number of your child's pediatrician AND any other doctor he/she is seeing. * Yes No If Yes Has your child ever been hospitalized or had a major operation? * Yes No If Yes Is your child on a special diet? * Yes No If Yes Is your child allergic to any of the following? Aspirin Latex Acrylic Penicillin Sulfa Drugs Local Dental Anesthetics Codeine Demerol or Phenergan Metal Valium If answered YES to any of the above, please describe the reaction: Other Allergies (environmental/nuts/animals) * Yes No If Yes Is your child taking any medications, inhalers, vitamins, pills, or drugs? * Yes No If Yes Does your child have, or had, any of the following? AIDS/HIV Positive * Yes No Diabetes * Yes No Hepatitis B or C * Yes No Rheumatic Fever * Yes No Epilepsy or Seizures * Yes No Excessive Bleeding * Yes No Excessive Thirst * Yes No Fainting Spells/Dizziness * Yes No Frequent Cough * Yes No Frequent Diarrhea * Yes No Frequent Headaches * Yes No Low Blood Pressure * Yes No Thyroid Disease * Yes No Tonsillitis * Yes No Cold Sores/Fever Blisters * Yes No Congenital Heart Disorder * Yes No Psychiatric Care * Yes No Cortisone Medicine * Yes No Hepatitis A * Yes No Renal Dialysis * Yes No High Blood Pressure * Yes No High Cholesterol * Yes No Hives or Rash * Yes No Hypoglycemia * Yes No Irregular Heartbeat * Yes No Kidney Problems * Yes No Leukemia * Yes No Liver Disease * Yes No Cancer * Yes No Chemotherapy * Yes No Heart Attack/Failure * Yes No Heart Murmur * Yes No Parathyroid Disease * Yes No ADD/ADHD * Yes No Hemophilia * Yes No Recent Weight Loss * Yes No Anemia * Yes No Rheumatism * Yes No Scarlet Fever * Yes No Shingles * Yes No Sickle Cell Disease * Yes No Sinus Trouble * Yes No Spina Bifida * Yes No Stomach/Intestinal Disease * Yes No Stroke * Yes No Glaucoma * Yes No Hay Fever * Yes No Osteoporosis * Yes No Autism Spectrum * Yes No Ulcers * Yes No Jaundice (not a birth) * Yes No Radiation Treatments * Yes No Anaphylaxis * Yes No Cold Sores/Fever Blisters * Yes No Arthritis/Gout * Yes No Artificial Heart Valve * Yes No Artificial Joint * Yes No Asthma * Yes No Blood Disease * Yes No Blood Transfusion * Yes No Breathing Problems * Yes No Bruise Easily * Yes No Lung Disease * Yes No Mitral Valve Prolapse * Yes No Tuberculosis * Yes No Tumors or Growths * Yes No Heart Trouble/Disease * Yes No Pregnant * Yes No If you answered YES to any of the above questions, please elaborate. Has your child ever had any serious illness not listed above? * Yes No If Yes Dental Questions Has your child ever had any "bad" dental experience in the past? * Yes No If Yes Has your child experienced any complications following dental treatment? * Yes No If Yes Has your child experienced prolonged bleeding following dental treatment? * Yes No If Yes Has your child experienced any clicking or pain in jaw joint? * Yes No If Yes Do you have family history of jaw surgery, missing teeth, or other dental issues? * Yes No Has your child had any dental trauma or injury to jaw or teeth? * Yes No To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. * Signature of Patient, Parent or Guardian: First Name Last Name Thank you for your submission! We look forward to your visit!
