New Patient Information

    CHILD HEALTH HISTORY UPDATE
    Please complete entire form
    Patient__________________________________________________________________
    Nickname _________________
    (First)
    (MI)
    (Last)
    Address______________________________________ City___________________ State______ Zip Code____________
    Sex M
    F
    Birthdate___________ Phone: Residence (______)_________________ Cell
    (______)_______________
    Mother’s Name__________________________________ Employer’s name & phone # __________________________
    Father’s Name___________________________________ Employer’s name & phone # __________________________
    With whom does the child reside? _____________________________________________________________________
    Who do we contact in case of emergency?__________________ Phone (______) ______________________________
    Relationship to Patient__________________________________
    DO YOU HAVE DENTAL INSURANCE?
    YES
    NO
    If yes, we will need a copy of your card and our green insurance form filled out.
    To the best of my knowledge, all information on this form is correct.
    Responsible Party Name________________________________
    Relationship to patient _______________________
    SIGNATURE OF RESPONSIBLE PARTY___________________________________________ DATE ________________
    Date________________
    www.blueridgedental.com
    DOES YOUR CHILD NOW HAVE OR EVER HAD ANY OF THE FOLLOWING?
    Yes No
    Heart murmur
    Heart valve dysfunction
    Rheumatic fever
    Prosthetic device
    (Hip or joint repl. pins, plates)
    Need to be premedicated due
    to a medical condition
    Abnormal blood pressure
    Blood transfusion
    Date ______________________________________
    Anemia
    Hemophilia / blood disorder
    Prolonged bleeding
    Positive to HIV
    Tuberculosis
    Autism
    Learning disability
    If yes, what type? ___________________________
    ADHD
    Psychiatric care
    Yes No
    Novocaine allergy
    Drug allergy
    If yes, what? ___________________________
    Other allergies
    If yes, what? ___________________________
    Tobacco use
    Smoking
    Hearing problems
    Radiation Therapy
    Cancer
    Sinus problem
    Stroke
    Thyroid disorder
    Ulcer
    Epilepsy
    Circulatory problems
    Diabetes
    Hepatitis
    Type_____
    Year________
    Asthma
    Taking any medication
    If yes, please list _______________________