Patient Information Children's History

your cooperation in filling out the data on this confidential questionnaire is essential in aiding us to perform the highest standard of dental care. All information is strictly confidential and will remain with this office.
Child's Full Name :
Age :
Sex :
Date Of Birth :

Address :

Dental Insurance :
Name Of Company :

Ins Policy No. :
Health Ins No. :
% Covered :

Family Physician :
Phone No. :
Previous Dentist :

Whom May We Thank For Referring You? :

In Case Of Emergency Notify :
Name :
Address :

Relationship :
Phone No. :

Name Of Person Responsible For Account :

Home Phone :
Date Of Birth :
Driver’s License No. :

Address :

Child’s History :
Nickname :
Usually Called :

Brother’s & Sister’s Names & Ages :

Favourite Toy :
Favourite Person :

School :
Favourite Sport :

Are You Seeking Treatment For Any Particular Reason And/Or Routine Dental Care? :

Other Comments :

Confidential Medical History
When did your child last visit the physician? :
Reason :

Has your child ever had any serious illness or been in the hospital? :
If so, describe :

Does your child have any known medical, physical or mental handicaps? :
If so, describe :

Has your child ever had any of the following?
Measles
Kidney Disease
Lung Disease
Heart Trouble
Scarlet Fever
Broken Bones
Epilepsy
Fainting Spells
Adenoids
Ear Trouble
Asthma
Mumps
Diabetes
Tuberculosis
Rheumatic Fever
Strep Throat
Operations
Liver Disease
Ankle Swelling
Abnormal Blood Pressure
Shortness of Breath
Hay Fever
Chicken Pox
Gland Trouble
Nervous Disorder
Chest Pains
Tonsils
Physical Deformity
Jaundice
Other Deformity

If yes to any of the above, describe :
Is your child allergic to any thing? :
If yes, describe :

Does he or she bruise easily or bleed profusely for a long period of time? :
Does your child have any blood disease? :
Does your child have any emotional problems? :

Is your child now taking, or has he or she had :
Penicillin
Local Anaesthesia
Other Antibiotics
General Anaesthesia
Cortisone
Other Drugs

Has he or she had any unfavourable reaction to these drugs? :

Is there a history of any inherited diseases in the family? :
If yes, describe :

Dental History
Has your child had previous dental care? :
when? :

Has he or she ever had an unpleasant experience with dental treatment? :
If yes, describe :

Has your child ever had an accident, injury or surgery about the mouth? :

Is there a family history of: (tick if yes)
High decay rate
Tooth deformity
Spaced teeth
Missing teeth
Extra teeth
Crooked teeth
Cleft lip or palate
Gum disease

If yes, describe :
Does your child have any oral habits such as: (tick if yes)
Thumb sucking
Finger sucking
Lip biting
Nail biting
Mouth Breathing
Teeth Grinding
Chewing (e.g. pencils)
Tongue Thrusting

Upon arrival to our office, you will be notified to sign the consent form for the treatment.

9 Prince Edward Street
Brighton, Ontario
K0K 1H0

Tel : (613) 475-1650

Email : info@chaggerdental.com