Pediatric Dentistry

Pediatric Dentistry
New England Dental Wellness Children's Dentistry

CHILD'S INFORMATION
Date*

MonthDayYear
Child’s Name: *

First NameMiddle NameLast Name
Preferred name*
MaleFemale
Age*
Birthdate:*

MonthDayYear
Place of Birth:*
Number of brothers*
Number of sisters *
OldestMiddleYoungest
School:*
Grade*
YESNO
If yes, please explain:
OutgoingRegular KidShyAnxiousHyperDefiantTrustingSuspiciousCooperativeMellowCuriousStubbornFriendlyMoody
Child’s Interests:
Favorite Sport:
Favorite Movie:
ExcellentGoodFairPoorDon’t Know
How can we make this a more positive experience for your child?*
Parent #1 Name:*
YESNO
Parent #2 Name:*
YESNO
IN CASE OF EMERGENCY, who should we contact? (Please specify someone who does not live in you household)
Name:*
Relationship:*
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
DENTAL HISTORY
Reason for today’s visit:*
YESNO
If no, date of last visit?*

MonthDayYear
Date of last X-rays:*

MonthDayYear
Work done:*
YESNO
If Yes, until what age?*
TeethMouthHeadJawsNone
If so, please describe:*
YESNO
YESNO
YESNO
YESNO
Finger SuckingThumb SuckingLip SuckingTongue ThrustingMouth BreathingTeeth GrindingNail BitingPacifierOther
In VitaminsIn Water SupplyIn ToothpasteIn Tablets/DropsIn Rinse/GelOther
MEDICAL HISTORY
Child's Name:*
Child’s Pediatrician:*
City:*
Phone:*

Area CodePhone Number
Date of Last Physical:*

MonthDayYear
YESNO
YESNO
YESNO
If so, please explain:*
YESNO
If so, to what? *
YESNO
If so, please explain:*
AIDS/HepatitisAllergies to MedicationsAnemiaAsthmaAutism SpectrumBladder ConditionsBlood TransfusionsBone or Joint ProblemsBrain InjuryBruising EasilyCancer or MalignanciesChronic HeadachesEar InfectionsEpilepsyConvulsions/SeizuresDiabetesTuberculosisEye ProblemsExcessive GaggingFainting or DizzinessDevelopmental DelayHearing/Speech ProblemsHyperactivityKidney/Liver DiseaseLeukemiaEmotional DisturbancesNutritional DeficiencyOral UlcersOrthopedic ProblemsRheumatic FeverScoliosisSickle Cell AnemiaSpina BifidaCerebral PalsyHeart ProblemsChild/sexual abuseHemophiliaTonsil ProblemsAttention Deficit DisorderSyndromeOther
Please describe any current medical treatment including drugs, pending surgery, recent injuries, hospitalizations or anY other information we should be aware of that has not been covered: *
Should be Empty: