Patient Information Form

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PATIENT INFORMATION
TODAY’S DATE _______________
Child’s Name ____________________ Surname: _________________________ Age:______ D.O.B:____________
Nickname: _____________________ Sex M/F: _____
Nationality: _________________________________
Address:________________________________________________________________________________________
Contact Tel: (Home)_____________________ (Mum)______________________ (Dad) _______________________
Email: ________________________________Parents Name – Mum: _______________ Dad: __________________
DENTAL HISTORY: Previous dental care: __________________ When: _____________ Trauma: _______________
Child’s response to past medical and dental care? ________________________________________________________
How do you feel your child will behave for dental care? __________________________________________________
e.g. thumb sucking/“soothers” etc
Oral Hygiene: ________________Oral habits (
.):________________________________
Referred by ______________________________________________________________________________________
Date of last dental visit ____________________ with whom _______________________________________________
Explain briefly, why you brought your child for dental care ________________________________________________
MEDICAL HISTORY:
Family physician or Pediatrician ______________________________Address:________________________________
Date of last medical examination _____________________________________________________________________
Is your child in good health? ___Yes ____No (explain) ___________________________________________________
Has your child ever had any of the following: (please tick only where appropriate)
A.D.H.D.
Bruising (excessive)
Hemophilia
Respiratory Problems
Allergies to Anesthetics
Chicken Pox
Hepatitis / Jaundice
Scarlet Fever
Allergies to Drugs/Medicines
Cold Sores
Kidney /
Sinusitis
Other Allergies:
Cystic Fibrosis
Liver Involvement
Skin Problems
Diabetes
Malignancies
Stroke
Anemia
Dyspraxia
Measles
Typhoid Fever
Asthma
Epilepsy / Seizures
Mumps
Tonsillitis
Autism
Fainting / Blackouts
Muscular Problems
Tuberculosis
Bleeding Disorders
Hay Fever
Nervousness
Bronchitis
Heart Problems
Psychiatric Tx
Yes
No
Is your child presently taking any medication or under active medical care?
___
___
Has your child taken corticosteroids during the past two years?
___
___
Has your child ever been hospitalised? Give details:______________________________
___
___
________________________________________________________________________
Are there any other aspects of your child’s health that you think might be important?
___
___
If so please specify: ___________________________________________________
Do you consider your child to be? (Please tick one):
__ advanced in the learning process;
__ progressing normally;
__ a slow learner
Because your child is a minor, your signature is necessary to give consent for
examination, photographs, radiographs (x-rays) & treatment where necessary:
Signed ________________________________ Print Name ______________________________ Date: __________
Following examination Dr Daly will discuss your child’s treatment plan with you
I hereby give consent for treatment as discussed with Dr. Daly
Signed ___________________________________ Date: ______________

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