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Patient Information

Patients Name__________________________________________________Name child goes by_________________


(First)

(Middle)

(Last)

Address___________________________________________________________________________________________
(Street)

(City)

Date of Birth:_________________ Patient Age ___

(State)

(Zip)

Sex___

Names of Siblings:
Childs Name __________________Age ___

Childs Name __________________ Age ___

Childs Name __________________Age ___

Childs Name __________________ Age ___

How did you learn about Scripps Pediatric Dentistry:_____________________________________________________


Best E-mail address (we do most our communication with you via email):___________________________________

Dental Insurance Information


Whos insurance is the child under:

Mother

Father

Insurance Co.__________________

ID No._____________

Social Security No. of policy holder _____________________


Does the child have a secondary dental insurance policy?

Other (Name)_______________________
Group No.__________
Birth date__________
Yes

No

Mothers Information:
Name __________________________________
Employer_____________________________Occupation_____________________________________________
Address if different from above_________________________________________________________________
Cell Phone_______________________

Home Phone__________________

Fathers Information:
Name __________________________________
Employer_____________________________Occupation_____________________________________________
Address if different from above_________________________________________________________________
Cell Phone_______________________

Home Phone__________________

I hereby authorize payment of the dental benefits otherwise payable to me directly to the above named
entity.
Responsible Party Signature ___________________________________________ Date__________
Form Modified 02/11

Patient Health History


Patient Name_______________________________________ Birth date: ____/____/____
Todays Date: ____/_____/______
Childs Physician________________________ Phone #:______._____._________
Who May We Thank For Referring You: ___________________________________________
Purpose of Todays Visit: ______________________________________________________________
Date of Last Dental Visit:_______/_________/__________ Previous Dentist: _____________________
1. Does your child have any specific medical condition - tuberculosis, cancer, cerebral palsy, etc.? If so,
specify__________________________________________________________________________________________

Yes

No

2. Does your child have any special limitations either mental or physical? If so,
specify__________________________________________________________________________________________

Yes

No

3. Has your child ever had an operation? If so, specify__________________________________________________

Yes

No

4. Have you ever been told that your child had/has a heart murmur, rheumatic fever, or a shunt?___________
If so, is antibiotic coverage needed for dental work?_________________________________________________

Yes
Yes

No
No

5. Does your child have asthma or breathing problems?___________________________________________ ____

Yes

No

6. Does your child have a history of seizures?_________________________________________________________

Yes

No

7. Has your child ever tested positive for Hepatitis or HIV? ______________________________________________

Yes

No

8. Does your child have any allergies to either:

Antibiotics
Analgesics
Latex ____________
Other(Specify)_________________________________
9. Is your child now taking any medicine? If so, specify_________________________________________________

Yes

No

Yes

No

10. Does your child have any learning disabilities, ADD or ADHD? If so, specify________________________

Yes

No

11. Has your child ever had a transfusion of whole blood or any blood products?_______________________

Yes

No

12. Does your child have any social difficulties?_________________________________________________

Yes

No

13. Is your child adopted or in foster care?_____________________________________________________

Yes

No

Yes

No

17. Was your childs pregnancy or delivery abnormal in any way?___________________________________

Yes

No

18. Was your child breast fed?______ Bottle fed?_______ Any difficulties? ___________________________

Yes

No

19. Has your child ever had a prolonged fever for any reason?______________________________________

Yes

No

20. Has your child ever had any unfavorable experience in a medical or dental office?___________________

Yes

No

21. Has your child ever had any injuries to the teeth, mouth, head or neck?
If so, explain_____________________________________________________________________________

Yes

No

22. Has the childs natural parents ever had a lot of decay or crooked teeth? __________________________

Yes

No

23. Is the childs mother or father afraid of dental care?___________________________________________

Yes

No

24. Has your child had a toothache lately? _____________________________________________________

Yes

No

25. Are there any other conditions or concerns not listed here? If so, please specify ____________________

Yes

No

14. Circle if parents are:

separated
divorced
widowed
never married
(We ask to help us better understand a childs emotional status)
15. Has your child had a history of thumb sucking, finger sucking, lip sucking, pacifier use or nail biting?
If so, explain_____________________________________________________________________________

26. How do you think your child will react to this dental visit? Very Poor

Poor OK Very Well No Idea

To the best of my knowledge the questions on this form have been accurately answered. I understand that
providing incorrect information can be dangerous to my childs heath.

Signature of Parent or Guardian_________________________ Date_______


From Revised 02/11