New Patient History
Children's DentistryJohn B. Witte D.D.S., P.C.3035 Matlock Road Arlington, TX 76015Phone: 817-784-1000Brush, Floss, Smile!
Child's Name
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Last Name
First Name
Date of Birth:
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Month
-
Day
Year
Date
Age:
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
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Male
Female
Parent/Guardian's Name:
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Cell Phone:
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Format: (000) 000-0000.
Medical Health History
General Health:
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Excellent
Good
Fair
Poor
Pediatrician:
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Date of Last Exam?
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Month
-
Day
Year
Date
Is child being treated for anything now?
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Are you Pregnant?
Medical Conditions
Epilepsy/Convulsions
Thyroid problem
Liver disease/jaundice
High Blood Pressure
Emotional Problems
Cancer/tumor/leukemia
Autism
Hearing problem
Speech problem
Asthma/lung problem
Cerebral palsy
Blood Disorder
Rheumatic fever
Developmental delay
Heart trouble/murmur
HIV/AIDS
ADD/ADHD
Kidney/urinary problem
Hepatitis
Diabetes
Bleeding Concerns
Allergies
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Penicillin
Codeine
Novocain
Latex/Rubber
Other
Does child have any allergies
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Does child have any other medical conditions that aren’t listed
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Current Medications
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Surgeries/Major Operations
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Dental Health History
Last dental visit:
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Previous Dentist:
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Reason for today's visit:
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Dental pain? If yes, when:
Negative dental experience?
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Yes
No
Injuries to mouth/teeth/face?
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Yes
No
If yes which area: Mouth / Teeth / Face
Speech problems?
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Mouth Breather?
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Yes
No
Thumb/finger sucking?
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Yes
No
Until what age?
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Teeth removed?
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Yes
No
Orthodontic treatment?
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Yes
No
Brushing times/day:
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Flossing times/week
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Fluoride:
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Topical
Water
Are you happy with the appearance of your child's teeth?
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Parent/Signature:
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Date:
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Month
-
Day
Year
Date
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