Child Health/Dental History Form

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Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M F Home Work Have you (the parent/guardian) or the patient had any of the following diseases or problems?... Yes 1. Active Tuberculosis, 2. Persistent cough greater than a three-week duration, 3.Cough that produces blood? If you answer yes to any of the three items above, please stop and return this form to the receptionist. No Has the child had any history of, or conditions related to, any of the following: Anemia Arthritis Asthma Bladder Bleeding disorders Bones/Joints Cancer Cerebral Palsy Chicken Pox Chronic Sinusitis Diabetes Ear Aches Epilepsy Fainting Growth Problems Hearing Heart Hepatitis Please list the name and phone number of the child s physician: HIV +/AIDS Immunizations Kidney Latex allergy Liver Measles Mononucleosis Mumps Pregnancy (teens) Rheumatic fever Seizures Sickle cell Thyroid Tobacco/Drug Use Tuberculosis Venereal Disease Other Name of Physician Phone Child s History Yes No 1. Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time?... 1. If yes, please list: 2. Is the child allergic to any medications, i.e. penicillin, antibiotics, or other drugs? If yes, please explain: 2. 3. Is the child allergic to anything else, such as certain foods? If yes, please explain: 3. 4. How would you describe the child s eating habits? 5. Has the child ever had a serious illness? If yes, when: Please describe: 5. 6. Has the child ever been hospitalized?... 6. 7. Does the child have a history of any other illnesses? If yes, please list: 7. 8. Has the child ever received a general anesthetic?... 8. 9. Does the child have any inherited problems?... 9. 10. Does the child have any speech difficulties?...10. 11. Has the child ever had a blood transfusion?...11. 12. Is the child physically, mentally, or emotionally impaired?...12. 13. Does the child experience excessive bleeding when cut?...13. 14. Is the child currently being treated for any illnesses?...14. 15. Is this the child s first visit to a dentist? If not the first visit, what was the date of the last dentist visit? Date: 15. 16. Has the child had any problem with dental treatment in the past?...16. 17. Has the child ever had dental radiographs (x-rays) exposed?...17. 18. Has the child ever suffered any injuries to the mouth, head or teeth?...18. 19. Has the child had any problems with the eruption or shedding of teeth?...19. 20. Has the child had any orthodontic treatment?...20. 21. What type of water does your child drink? City water Well water Bottled water Filtered water 22. Does the child take fluoride supplements?...22. 23. Is fluoride toothpaste used?...23. 24. How many times are the child s teeth brushed per day? When are the teeth brushed? 24. 25. Does the child suck his/her thumb, fingers or pacifier?...25. 26. At what age did the child stop bottle feeding? Age Breast feeding? Age 27. Does child participate in active recreational activities?...27. NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Parent s/guardian s Signature Date For completion by dentist Comments For Office Use Only: Medical Alert Premedication Allergies Anesthesia Reviewed by Date American Dental Association, 2006 To Reorder call 1-800-947-4746 Form S707 or go online at www.adacatalog.org

Dental Arts By Lena Cosmetic and General Dentistry Lena J Salha, DDS 4041 Steck Ave. Austin, TX 78759 phone: 512-345-0400 Fax: 512-345-0402 Assignment and Authorization of Benefits I hereby give authorization for payment of insurance benefits to be made directly to Dental Arts By Lena, PC. for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In event of default, I agree to pay all costs of collection and reasonable attorney fees. I hereby authorize this Dental care Provider to release all information necessary to secure payment benefits. I further agree that a photocopy of this Agreement is as valid as the original. Authorization for E mail & Voicemail Usage for PHI I hereby give permission to leave a message on my voicemail concerning my personal dental health information I Agree with Option I Decline Option I hereby give permission to communicate, via e mail address listed on my patient information questionnaire, my personal dental health information I Agree with Option I Decline Option Patient Signature or Guardian signature if a minor Date Witness Signature Date

POLICY HOLDER AND INSURANCE INFORMATION Last Name: First Name: MI: Address: Apt#: City State Zip Home#: Work#: Cell#: Age: Sex: M F Date of Birth: Marital Status: SS#: Driver s License number: State: Employer s Name: Occupation: E- Mail Address: Preferred Pharmacy / Pharmacy phone #: EMERGENCY CONTACT NAME & PHONE NUMBERS: SPOUSE INFORMATION Name: Phone Numbers: Home: Cell: Work: Address: Apt#: City State Zip Age: Sex: M F Date of Birth: SS#: Employer s name: Occupation:

DENTAL INSURANCE INFORMATION PRIMARY DENTAL INSURANCE: Address: State/City/ Zip ID#: Policy# Name of policy Holder: Date of birth of policy Holder: SS# of policy Holder: Relationship to Patient: Patient Primary Care Doctor: Phone number: How did you learn about our office:

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