Patient Information And Medical History Form

ADVERTISEMENT

Rhonda L. Kearney, DDS, MS, PLLC
Henderson Pediatric Dentistry
451 Ruin Creek Rd., Suite 205 • Henderson, NC 27536 • Tel: (252) 492-KIDS (5437) • Fax: (252) 492-5440
PATIENT INFORMATION AND MEDICAL HISTORY FORM
Date: ___________________________
Patient’s Name: ______________________________________________________ Age: __________ Sex: ___________
Date of Birth_____/_____/______ Grade: __________ School: ______________________________________________
Address: ___________________________________________City: ____________________State:____ Zip:__________
Home Phone:______________________________________ Patient’s Social Security Number: _______-_____-_______
Guardian’s email: ___________________________________________________________________________________
PARENT INFORMATION
Parent/Legal Guardian 1: __________________________________________ Relation to patient:___________________
Employer:___________________________________ Phone:__________________________ Date of Birth ___/___/____
Parent/Legal Guardian 2: __________________________________________ Relation to patient:___________________
Employer:___________________________________ Phone:__________________________ Date of Birth ___/___/____
Who has legal custody of patient? _________________________________________ Dental Insurance: □Yes □ No
Person responsible for payment of account _________________________ SSN#/Member ID#: _____________________
Driver’s License #___________________________________
Marital Status of Parents: Married / Separated / Divorced / Other: ______________________________________
WHOM MAY WE THANK FOR REFERRING YOU TO US?
Name: ___________________________________________________________________________________________
□ From a Friend
□
□Phone Book
□Dental Office
□Pediatrician/Doctor
□Other
EMERGENCY CONTACT (other than parents)
Name: ______________________________________________________________ Relationship: __________________
Home Phone: _____________________Work Phone: ____________________ Mobile: ___________________________
HEALTH PROVIDER
Child's Physician/Pediatrician: ________________________________________ Phone#: _________________________
Mailing Address: _____________________________________ City: _________________ State:____ Zip: ___________
DENTAL HISTORY
What is the reason for your child’s dental visit?____________________________________________________________
□ Yes □ No
Has your child ever been to the dentist? Date of last cleaning & x-rays (if taken)____________________
Name of previous dentist: ______________________________________Phone: ___________________
□ Yes □ No
Has your child experienced any unfavorable reaction from previous dental care?
Explain ______________________________________________________________________________
□ Yes □ No
Does your child suck a finger, thumb, or pacifier? Which one? __________________________________
□ Yes □ No
Does your child go to bed with a bottle or sippy cup? If so, what is in it? __________________________
□ Yes □ No
Does your child snack frequently? What are their favorite snack foods? ___________________________
□ Yes □ No
Has your child had local anesthetic? Were there any problems? __________________________________
□ Yes □ No
Has your child been sedated for dental treatment? Were there any problems? _______________________
□ Yes □ No
Have your child’s teeth ever been injured? Which teeth: _______________________________________
Dental treatment for trauma: _____________________________________________________________
□ Yes □ No
Has your child or anyone in your immediate family ever had a cavity? If so, who and when?___________
_____________________________________________________________________________________
Please check if your child is having problems with any of the following:
□ Cavities
□ Orthodontics
□ Sensitive Teeth
□ Mouth Breathing
□ Trauma
□ Gum Infections
□ Color of Teeth
□ Other
□ Toothaches
□ Jaw Sounds
□ Grinding of Teeth
Explanations and Comments: __________________________________________________________________________
__________________________________________________________________________________________________
---(OVER)---

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Registration And Medical History Form Patient Registration And Medical History Form Medical
Patient Ocular And Medical History Form Patient Ocular And Medical History Form Medical
Patient Information And Medical History Patient Information And Medical History Medical
Patient Registration And Medical History Form - Glacier Valley Endodontics Patient Registration And Medical History Form - Glacier Valley Endodontics Medical
Pediatric Dentistry Of North Texas Patient Information And Health History Form Pediatric Dentistry Of North Texas Patient Information And Health History Form Medical
Patient Information-family Medical Center Form Patient Information-family Medical Center Form Medical
Patient Registration And Health History Form Patient Registration And Health History Form Business
Patient Registration And Health History Form Patient Registration And Health History Form Medical
Medical And Physical Condition Standard Information And Medical Release Form Medical And Physical Condition Standard Information And Medical Release Form Legal
Form 10 - 0804: Dental And Medical History Form Form 10 - 0804: Dental And Medical History Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2