• Pediatric Dentistry

  • New England Dental Wellness Children's Dentistry

     

    CHILD'S INFORMATION

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Birthdate:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this child the*
  • Has your child had any bad dental or medical experiences in the past?*
  • Please check any of the following that may describe your child*
  • How do you expect your child to react to his/her visit today?*
  • Current Patient?*
  • Current Patient?*

  • IN CASE OF EMERGENCY, who should we contact? (Please specify someone who does not live in you household)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTAL HISTORY

  • Is this your child’s first dental visit?*
  • If no, date of last visit?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last X-rays:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Was your child breast fed?*
  • Has your child ever had any injuries to his/her:*
  • Does your child brush daily*
  • Does an adult assist with the brushing?*
  • Does your child floss?*
  • Does an adult assist with the flossing?*
  • Does your child have any of the following mouth habits?*

  • Does your child receive fluoride in any of the following form?*

  • MEDICAL HISTORY

  •  -
  • Date of Last Physical:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is your child in good health?*
  • Does your child need to be pre-medicated before dental treatment?*
  • Is your child being treated for any conditions presently?*
  • Does your child have any allergies or reactions to any medications?*
  • Has your child ever been hospitalized or had surgery?*
  • Has your child ever been diagnosed as having any of the following conditions?*

  • Should be Empty: