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NEW PATIENT FORM

770.692.1000 |

Medical History

Is your child presently under the care of your family physician for

any medical reason? ❏ Yes ❏ No If yes, explain ________________

About Your Child

______________________________________________________________

Family Physician’s Name:______________________________________

Address: _____________________________________________________

______________________________________________________________

Child’s Name

Phone Number: _______________________________________________

______________________________________________________________

• Is your child in good health? If no, explain ______

❏ Yes ❏ No

Name Child Prefers To Be Called

_____________________________________________

______________________________________________________________

• Is your child under the care of a physician for

❏ Yes ❏ No

Age

Gender

Date of Birth

other than routine care? If yes, explain _________

______________________________________________________________

_____________________________________________

Address

Apt

• Does your child have any drug allergies? If yes,

❏ Yes ❏ No

explain _____________________________________

______________________________________________________________

City

State

Zip

• Is your child taking any medications at this

❏ Yes ❏ No

time? If yes, list. _____________________________

______________________________________________________________

_____________________________________________

Home Phone

Patient’s School District (county/city)

• Has your child ever been hospitalized or treated

❏ Yes ❏ No

______________________________________________________________

in an emergency room for any particular trauma?

Grade Level

Patient’s Hobbies/Pets

When and for what reason? ___________________

______________________________________________________________

_____________________________________________

Other Children and Their Ages

• Does your child have, or has he or she had, any

❏ Yes ❏ No

______________________________________________________________

emotional, mental or nervous disorders? If yes,

Referred To Our Office By (We Wish To Thank Them)

please explain. ______________________________

_____________________________________________

Parent’s Marital Status:

• Have your child’s tonsils and/or adenoids been

❏ Yes ❏ No

❏ Married ❏ Divorced ❏ Separated ❏ Widowed ❏ Single

removed?

• Does your child breathe through the mouth?

❏ Yes ❏ No

If yes,

Seldom

Often

❏

Please indicate if your child has had any of the following:

Dental History

❏ Allergy to Penicillin

❏ Intellectual disability

❏ Anemia

❏ Latex allergy/sensitivity

❏ Yes ❏ No

Is this your child’s first visit to the dentist? If no,

❏ Asthma

❏ Liver problems or hepatitis

when was the last visit and what was done for your

❏ Autism/Asperger’s Syndrome

❏ Malignancies or leukemia

child?

❏ Bleeding disorder

❏ Other drug allergy

❏ Bone disorder

❏ Physical handicap

Do you expect your child to be a cooperative patient?

❏ Yes ❏ No

❏ Cleft palate

❏ Positive for H.I. V .

If no, please explain.

❏ Diabetes

❏ Radiation treatment

❏ Endocrine disorder

❏ Rheumatic fever

❏ Yes ❏ No

Do you have well water at home?

❏ Epilepsy, seizures

❏ Speech problem

Does your child take fluoride tablets or vitamins

❏ Yes ❏ No

❏ Hyperactivity/ADD/ADHD

❏ Tuberculosis

with fluoride?

❏ Heart ailment or murmur. Type, if known________________

❏ Yes ❏ No

Has your child bumped any teeth? If so, when?

Is child under the care of a cardiologist or special physician

for the problem? If so, whom ______________________________

❏ Yes ❏ No

Has your child had a history of headaches, pain,

Phone ___________________________________________________

popping or clicking of the jaws?

Please comment on any problems that were checked in the

❏ Yes ❏ No

Does your child still have a night time bottle?

above areas ______________________________________________

❏ Yes ❏ No

Does your child have a toothache?

__________________________________________________________

Does your child have or has he or she had any of the following

Do you consider your child to be:

problems or habits?

• Advanced in the learning process

❏ Yes ❏ No

❏ Thumb Sucking

How Long?______ Still Active ❏ Yes ❏ No

• Progressing normally

❏ Yes ❏ No

❏ Finger Habit

How Long?______ Still Active ❏ Yes ❏ No

• A slow learner

❏ Yes ❏ No

❏ Pacifier

How Long?______ Still Active ❏ Yes ❏ No

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