ext2 PATIENT INFORMATION Child’s Name Date Home Address Phone Sex MF Age Birth Date Nick Name Names and Ages of Brothers and Sisters Hobbies, Pets, Favorite TV Shows, etc. Person Responsible for this Account Email Whom may we thank for referring you? DENTAL HISTORY Reason for this visit (1st examination, check-up, toothache, etc.) Has your child ever had an injury to the mouth, teeth or jaws (fall, blow, etc.)? How long since last visit to a dentist? Was the dental experience pleasant or unpleasant? If unpleasant, how did he/she react? Did he/she object to anything in particular? Does your child have any history of thumb or lip sucking, pacifier, nail or lip biting? If yes, please explain Does your child use fluoride toothpaste? Has your child ever taken fluoride supplements or vitamins with fluoride? MEDICAL HISTORY Child’s physician/pediatrician City Phone Is your child in good health? Is your child taking any medications? Is your child allergic to any medicines? General allergies? Any history of cerebral palsy, seizures, fainting, or loss of consciousness? NoYes Any sensory disorders? (seeing, hearing, Sensory Integration Disorder) NoYes Has your child been diagnosed with PDD, autism, ADHD or ADD? NoYes Any history of congenial heart disease, heart murmur or rheumatic fever? NoYes Has any heart surgery been done or recommended? NoYes Has your child ever had a blood transfusion? NoYes Any history of anemia or sickle cell disease? NoYes Does your child bruise easily or bleed excessively from small cuts? NoYes Any history of pneumonia, cystic fibrosis, asthma, or difficulty breathing? NoYes Any history of stomach, intestinal, kidney or liver problems? NoYes Any history of hepatitis? NoYes Any history of diabetes? NoYes Any history of thyroid disease or other glandular disorders? NoYes Has your child ever been hospitalized? NoYes (If yes, please explain) Is your child up to date with immunizations? (DPT, IPV,MMR, HIB, HepB) NoYes Any additional related problems? To the best of my knowledge, the above information is complete and accurate.