Millhopper Pediatric Dentistry Patient Information
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1MILLHOPPER PEDIATRIC DENTISTRY, PL
MILLHOPPER PEDIATRIC DENTISTRY, PL
MILLHOPPER PEDIATRIC DENTISTRY, PL
MILLHOPPER PEDIATRIC DENTISTRY, PL
PATIENT INFORMATION
Patient Name_______________________________________________DOB_________________ Sex__________ Chart #____________
Dental
Yes
No
Has your child ever been seen by a dentist?
___
___
•
Will your child be a cooperative dental patient?
___
___
•
Does your child suck fingers or thumb or have similar habits?
___
___
•
Does your child participate in sports activities?
___
___
•
Is your community water supply fluoridated?
___
___
•
Have you ever given your child vitamins or tablets with fluoride?
___
___
•
Does your child brush regularly?
___
___
•
Does your child floss regularly?
___
___
•
Health
Is your child presently being treated by a physician?
___
___
•
Is your child immunization up-to-date?
___
___
•
Does your child have any drug allergies?
___
___
•
Is your child currently taking any medication?
___
___
•
Has your child ever been a patient in a hospital?
___
___
•
Has your child ever been a patient in an emergency room?
___
___
•
Place a check if your child has (had) problems with the following:
Yes
No
Yes
No
Yes
No
Yes
No
Heart
___
___
Liver
___
___
Asthma ___
___
Allergies ___
___
Heart murmur
___
___
Hepatitis ___
___
Diabetes ___
___
Speech
___
___
Rheumatic Fever
___
___
Kidney ___
___
Epilepsy ___
___
Emotions ___
___
Bleeding
___
___
Muscles ___
___
Bones
___
___
Other
___
___
If any of the above answers are yes, please explain:
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Signature_____________________________________________Relationship_______________________________Date______________
********************** For Office Use Only************************
Radiographic Record
Height/Weight Record
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BW
Pan
PA
Occl
Date
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Wt(#)
Date
Ht(in)
Wt(#)
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Parent category: Medical