New Patient New Patient Child’s Name Child's Name First First Middle Middle Last Last Goes By Nickname Date of Birth * Age Gender Male Female Medicaid or Texas CHIP * Yes No Medicaid / ID Number Home Address * Home Address Home Address Home Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Name of person who is accompanying your child today? * Relationship to child * Does this person have legal custody of this child? * Yes No Is your child adopted? * Yes No Child primarily lives with: * Both parents Mother Father Grantparent(s) Other Child primarily lives with: Parent(s) / Guardians are: * Married Single Divorced Separated Widowed Partnership Do you have other children seen by us? * Yes No Their Names: Nearest relative not living with you Nearest relative not living with you First First Last Last Relationship Phone Do you or does any family member have a dental background or is employed in the dental field? Yes No Please explain How did you hear about our office? * Internet Insurance company School Work Sign Previous patient of record Another patient, friend Relative Pediatrician Dental office Name of the person who told you about our office Main Contact Parent/ Guardian Information Name * Name First First Last Last Relationship * Birthdate * SSN * xxx-xx-xxxx Driver’s License * State * Email * Cell Phone Home Phone Work Phone Ext Is this parent’s address the same as the child’s? * Yes No Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Employer * Language spoken * Additional Parent/ Legal Guardian Information Name Name First First Last Last Relationship Birthdate SSN xxx-xx-xxxx Driver’s License State Email Cell Phone Home Phone Work Phone Ext Is this parent’s address the same as the child’s? Yes No Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Employer Language spoken Add Parent / Guardian Remove Please add information for any person who has legal custody of your child or else we will be unable to discuss patient information with that person Reason for today’s visit (check all that apply) First visit to a dentist Check-up Cavity Pain Accident OtherOther Name of previous dentist Date of last visit For what service? Dental History What is your child’s attitude toward visiting the dentist? * Positive Neutral Negative Has your child complained about dental problems? * No Yes (please explain)Yes (please explain) Has your child had any unhappy dental experiences? * No Yes (please explain)Yes (please explain) Has your child had any injury to the mouth, head or teeth? * No Yes (please explain)Yes (please explain) Does your child brush teeth daily? * No Yes Is floss used? * No Yes Sometimes Do YOU assist with tooth brushing? * No Yes (How often?)Yes (How often?) Does your child have any of the following mouth habits: Thumb / Finger sucking Nail biting Mouth breathing Pacifier Lip biting / sucking Speech impairment OtherOther Is your child currently * Nursing Bottle Fed G-Tube Fed None of the above Medical History Child’s physician * Address * Phone Date of last physical examination * Results * Is child under the care of a physician now? * No Yes, reason: Yes, reason: Is child receiving medication / drugs? * No Yes, what:Yes, what: Has child ever been hospitalized? * No Yes, what reason: Yes, what reason: Has child ever had surgery? * No Yes, what reason: Yes, what reason: Is there any allergy to penicillin or other drugs? * No Yes, what: Yes, what: Are there any other allergies (Latex, Metal, Food, Pollen, Animal, Dust, Dye, etc)? * No Yes, what: Yes, what: Has your child ever had a blood transfusion? * No Yes Are there any emotional problems? * No Yes, please describe: Yes, please describe: Has child had any reactions to anesthetics local and/or general? * No Yes, please describe: Yes, please describe: Has child had any reactions to sedative agents? * No Yes, please describe: Yes, please describe: Has this child had any treatment on any of the following? Blood/ Circulatory No Yes Gastrointestinal (stomach) No Yes Muscles No Yes Endocrine glands No Yes Kidney / Bladder No Yes Nervous System No Yes Eyes, Ears, Nose, Throat No Yes Liver No Yes Skin No Yes Has this child ever been diagnosed as having any of the following conditions? ADD / ADHD No Yes Emotional Disorder No Yes Pneumonia No Yes AIDS / HIV No Yes Epilepsy / Seizures No Yes Pregnancy No Yes Anemia No Yes Eye Problems No Yes Rheumatic Fever No Yes Allergy No Yes Excessive Bleeding Problem No Yes Scarlet Fever No Yes Arthritis No Yes Fainting No Yes Scoliosis No Yes Asthma No Yes Hearing Loss No Yes Sickle Cell Anemia No Yes Autism Spectrum Disorder No Yes Heart Disease / Heart Murmur No Yes Sinus Problems No Yes Brain Injury No Yes Hemophilia No Yes Sleep Apnea No Yes Bronchitis No Yes Hepatitis No Yes Snoring at Night No Yes Type of Hepatitis * Cancer No Yes Jaundice No Yes Sore Throats (Frequent) No Yes Cerebral Palsy No Yes Leukemia No Yes Spina Bifida No Yes Chicken Pox No Yes Measles No Yes Syndrome No Yes Explain * Cleft Lip / Cleft Palate No Yes MRSA No Yes Tetanus No Yes Congenital Birth Defect No Yes Mumps No Yes Tuberculosis No Yes Developmentally Delayed No Yes Mouth Breathing No Yes Venereal Disease No Yes Diabetes No Yes Nutritional Deficiency No Yes Whooping Cough No Yes Type of Diabetes * ex: Type 1, Type 2 Drug, Alcohol, Tobacco Use No Yes Orthopedic Problems No Yes Other Is there anything else that you think we should know about your child? I give my consent for my child to have a * dental exam teeth cleaning fluoride treatment x-rays I certify that I have read and understood the above questions. I will not hold Northeast Children’s Dentistry, Inc. or any member of its staff responsible for any errors or omissions I may have made in completion of this form. I authorize the release of information to all of my insurance companies. I understand that I am responsible for all financial responsibilities. * Your name * Relationship to patient * Signature * Clear Date If you are human, leave this field blank. Submit Δ
