HEINE FAMILY DENTAL - CHILD NEW PATIENT

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NOTE: The parent or guardian who accompanies the child is responsible for payment at the time of service.

HEALTH HISTORY FORM

1. Tell Us About Your Child
Sex *
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2. Who may we thank for referring you to our office?

3. Mother's Information
Relationship to Child: *
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4. Father's Information
Relationship to Child: *
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5. Who is Accompanying the Child Today?
Do you have legal custody of this child? *

6. Person Responsible for Account

7. Primary Dental Insurance
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8. Secondary Dental Insurance
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9. Dental History
Were any x-rays taken at previous dental visits?
Have there been any injuries to the teeth, face or mouth?
Does the child have any of the following habits?
 YesNo
Lip Sucking/Biting
Nursing/Bottle Habits
Nail Biting
Thumb/Finger Sucking
Has the child ever had a serious or difficult problem associated with previous dental work?
Is the child's water fluoridated?
Is the child taking fluoride supplements?
Has the child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TD)?
Does the child brush his/her teeth daily?
Floss his/her teeth daily?

10. Health History
Has the child ever had any of the following conditions?
 YesNo
Abnormal Bleeding
Allergies to any Drugs
Any Hospital Stays
Any Operations
Asthma
Cancer
Congenital Birth Defects
Convulsions/Epilepsy
Pregnancy
Tuberculosis
ADD/ADHD
 YesNo
Disabilities/Special Needs
Hearing Impairment
Heart Disease/Murmur
Hemophilia/Blood Disorders
Hepatitis
HIV/AIDS
Kidney/Liver Conditions
Rheumatic/Scarlet Fever
Allergies to Latex Products
Diabetes
Autism
Is the child currently under the care of a physician?
Please describe the child's current physical health:
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

11. AUTHORIZATION
 
 
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.
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For Office Use Only

I verbally reviewed the medical/dental information above with the parent/guardian and patient named herein.
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