*Child’s Name (Last, First, MI):          Preferred name:

*Sex:        Male Female     *Age:              *Birth date:             *SSN:      

School:    Grade:     City:

Number of brothers?    Number of sisters?     Age Rank: Eldest Middle Youngest

Siblings' Names:

Please click any of the following that may describe your child (hold Ctrl while clicking for multiple):
Outgoing Regular Kid Shy Anxious Stubborn Hyperactive Trusting Suspicious Cooperative Mellow Curious Defiant Friendly Moody

Child’s Interests (toy, sport, hobby, person, pet, etc.):
How do you expect your child to react to his/her visit today? Excellent Good Negatively Very Negatively Don't Know
How can we make this a more positive experience for your child?
Who may we thank for referring you to our office?

Medical History
Pediatrician:    Phone number:
Date of last medical exam:
*Is your child in good health?       Yes No        *Are the immunizations up to date?       Yes No
*Is your child under the care of a physician now?       Yes No        If yes, Why?
*Is your child taking any medication or drugs?       Yes No        If yes, Which?
*Ever been hospitalized?       Yes No        If yes, Why?
*Ever had surgery?       Yes No        If yes, What/Why?

*Click any of the following your child has or has had: (Hold Ctrl to Click Multiple)
  Asthma Anemia Bladder Problems Blood Transfusion Bruising Easily Cancer Cerebral Palsy Chicken Pox Cleft Lip/Palate Convulsions Developmental Disability Diabetes Ear Infections Emotional Disturbance Epilepsy Fainting/Dizziness Hay Fever Hearing Problems Heart Problems Hepatitis Jaundice Juvenile Rheumatoid Arthritis Kidney Disease Liver Disease Measles Mumps Mononucleosis Prematurity Rheumatic Fever Sinus Problems Tonsil Problems Thyroid Problems Tuberculosis Venereal Disease

*Any history of allergy/adverse reaction to the following? (Hold Ctrl to Click Multiple)
Aspirin Amoxicillin Babiturates Local Anesthetics Metal (rings/earrings) Penicillin Sedatives Sleeping Pills Sulfa Drugs Latex
Any others?

*Is there any family history of any bleeding/bruising, drug allergies, asthma, other family disorders?       No Yes
Please explain any positive responses below:

*Is this your child’s first visit to the dentist?       Yes No
Name of previous dentist:
Phone number: Date of last visit:
Services Performed Last Visit:

*Does your child need to take antibiotics before dental treatment?       Yes No
If so, medication used:
*Has your child had any trouble associated with previous dental treatment?       Yes No
*Has your child been cooperative with physicians and dentists in the past?       Yes No
Have you been satisfied with your previous dental care? Yes No
*Does your child brush regularly?       Yes No
*Does your child floss?       Yes No
*Do the gums bleed when brushing or flossing?       Yes No
*Does your child take fluoride in any form? (water, toothpaste, fluoride pills)       Yes Don't Know No
*Does your child have any sensitivity to hot/cold or sweet/sour?       Yes No
*Does your child have any pain in his/her mouth?       Yes No
*Does your child gag excessively?       Yes No
*Does your child snore?       Yes No
*Has your child ever had any orthodontic work?       Yes No
*Has your child ever complained of jaw joint pain or problems?       Yes No

*Does your child have any mouth habits? (Hold Ctrl to Click More Than One)
  None Teeth Grinding Thumb Sucking Finger Sucking Nail Biting Cheek/Lip Biting Mouth Breathing Uses Bottle Pacifier

*Any injury to any teeth, mouth, head or jaws by a fall, bump, etc?       Yes No
*Any unusual speech habits?       Yes No
Any lost or missing teeth? Yes No
Any unusual family dental history, such as missing or extra teeth? Yes No
Do you desire complete dental services for your child? Yes No
Do you desire cosmetic dental restorations for your child? Yes No
Do desire sedation for your child during dental treatment? Yes No
Comments:

Parent Information
*Responsible Parent/Party Name:      *Relationship to Patient:      Father Mother Legal Guardian Other

*Address:
*City:    *State:     *Zip:

*Pref. Phone:           Alt Phone / Pgr:     *E-mail:         

*Date of Birth: *SSN:     *Driver License/ID #:       

Occupation:      Employer Name:
Employer Address:
City:State:      Zip:    Work Phone:

Spouse’s Name:
    Check if Address Info is Same As Responsible Party
Address:
City:  State:    Zip:
Home Phone:    Alt Phone / Pager:E-mail:

Date of Birth:    SSN:     Driver License #:

Occupation:    Employer Name:
Employer Address:
City:     State:        Zip:    Work Phone:

*Who does the child live with?        Both Parents Mother Father Other

EMERGENCY CONTACT (someone who does not live in your home)
*Name:       *Relationship:      
*Home Phone:               *Work Phone:      

Insurance Information
Name of Carrier: Phone:
Address:
Subscriber Name:  Subscriber DOB:  Relationship to Pt:
Subscriber SSN:     Member Number:
Policy Number:     Employer:
How long have you had this insurance?

Secondary Insurance Carrier: Phone:
Address:
Name of Subscriber:      Relationship to patient:
Subscriber SSN:       Member Number:
Policy Number:      Employer:

Please review your information carefully.  Once submitted, you cannot use the Back button to make changes.

Authorization
The information I have given is correct to the best of my knowledge.  I understand it will be held in the strictest confidence.  I understand that it is my responsibility to inform this office if there are changes in my child’s health status.

*Enter your initials:          

All information collected is securely transmitted to a secure email account and is not kept on a public web server.  Information is used solely for patient care and contact and is not shared or sold under any circumstances.  If you have any concern regarding the confidentiality of your information, please call our office directly or email us at info@kidcareoc.com.  Privacy Policy