Order Number Today's Date * Child's First Name * Last Name * Nickname Birthday * Age * Gender * Male Female Weight Parents Name * Relationship to Child * Mother, Father, Aunt, Uncle Grandparent etc. Parent's Birthday * Phone Number * Address * City * State * AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code * Email Address * Occupation/Employer Additional Parent or Guardian Any other person that may accompany your child to their visit Dental Insurance Company (This may be a different company than your child's medical insurance) Name of Subscriber Subscriber's Birthday Subscriber or Member ID Number This could be the subscriber's social security number if you didn't receive a dental insurance card. Name of Pediatrician Name of Any Medical Specialists Please list any medications (prescriptions, vitamins or supplements) Please list any allergies Please list any hospitalizations, surgeries or other significant injury/illness MEDICAL HISTORY FOR THE FOLLOWING QUESTIONS YOU ONLY NEED TO CLICK IF THE ANSWER IS YES. PLEASE PROVIDE DETAILS AT THE END OF THE SECTION FOR ANY POSITIVE RESPONSES. Was your child born prematurely (before 36 weeks gestation)? Yes No If yes, what week and please describe any complications after birth Any Problems with growth & development, birth defects, syndromes or inherited conditions? Yes No Heart problems (including congenital heart defects/disease, heart murmur, irregular heart beat or high blood pressure Yes No Asthma or breathing problems Yes No Bladder and/or kidney problems Yes No Jaundice, hepatitis or liver problems Yes No Gastroesophageal/acid reflux or stomach problems Yes No Developmental disorder, learning problems/delays, autism, cerebral palsy, ADD/ADHD Yes No Epilepsy, convulsions/seizures Yes No Diabetes, thyroid or other endocrine problems Yes No Hemophilia, bleeding disorder or taking anticoagulation medications Yes No Cancer or other malignancies Yes No History of problems with sedation and/or anesthesia Yes No Infectious diseases (hepatitis, HIV/AIDS, MRSA, Tuberculosis, endocarditis, frequent/recurrent infections, or infections requiring hospitalization/IV antibiotics Yes No If yes to any of the above or other medical problems we should know about, please explain below DENTAL HISTORY Any particular concerns for your child's teeth? Any history of cavities, traumatic injuries or other dental problems? Any jaw joint problems (pain, clicking or popping)? Yes No Does your child have any habits? Thumb or finger sucking Pacifier Mouth breathing Grinding/clenching Nail Biting Other Does your child sleep with a bottle or sippy cup? Yes No Ages 5 and under only What does your child drink most often? What kind of toothpaste do you use? * With flouride Without flouride Not sure Has your child ever undergone orthodontic treatment? If yes, please describe and list name of treating orthodontist Has your child ever had a difficult dental appointment? * Yes No If yes please explain Is there anything else we should know before treating your child?