Kid s Smiles, inc PEDIATRIC PATIENT INFORMATION & HEALTH HISTORY FORM
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1 Kid s Smiles, inc Lorraine Lewis, D.D.S. Pediatric Dentist Please complete and bring to 1st visit Reviewed by 407 North Street Hyannis, MA Phone (508) Fax (508) Specialist in dentistry for children & adolescents Dr. Date PEDIATRIC PATIENT INFORMATION & HEALTH HISTORY FORM Child s Name Nickname D.O.B. Mailing Address: Street Place of Birth City State Zip Tel. # Cell # Mother s Name Occupation Bus. Tel. # Father s Name Occupation Bus. Tel. # Billing Address: Street City State Zip (if different than above) Marital Status: Married Single Separated Divorced Widowed Other Child Lives With: Both Parents Mother Father Other Address: Child s Physician Street Tel. # City State Zip Pharmacy Name Address City Child s Previous Dentist Names and Ages of Siblings D.O.B. D.O.B. Whom may we thank for referring you? Whom may we contact in case of emergency? Name Relationship Tel # General Information Who is accompanying the child today? Name: Relation: Do you have custody of this child or are you the legal guardian? Yes No
2 Reason(s) for seeking dental care: DENTAL HEALTH HISTORY First examination Appearance of teeth 2nd Opinion Routine Check-up Crowding of teeth Consultation Toothache or swelling Accident Orthodontic Eval. Other If your child has been to a dentist previously, When was the last visit? Have x-rays been taken and when? Date How did your child react and describe his/her temperament? Has your child had local anesthetic ( Novacaine )? Were there any complications? How do you think your child will react to dental treatment? Has your child had fluoride in any of the following forms? Fluoride tablets or fluoride in multi-vitamins Drinking water (community water fluoridation) Professional topical application Does your child brush his/her own teeth? How frequently and when A.M. P.M. After Breakfast Snack Before Bed Do you assist in brushing your child s teeth? When? Do you or your child use dental floss in cleaning their teeth? What kind of toothbrush does he or she use? Hard Soft Does your child snack frequently? If yes, what do those snacks usually consist of? Have your child s teeth ever been injured? When? (Age) Which teeth? Cause? Did he/she receive treatment? If yes, describe treatment Does your child have any of the following habits? (Indicate inclusive ages) Bottle with milk/juice to sleep or nap Thumb sucking Finger sucking Pacifier sucking Mouth breathing Has your child received any unusual dental or surgical treatment to the mouth? If yes, describe
3 MEDICAL HISTORY Were there any difficulties during the pregnancy, delivery (e.g. prematurity), or first year of your child s life? If yes, describe Is a physician currently treating your child for a specific illness? If yes, for what reason? Is your child currently taking any medications? Drug Reason Has your child taken any unusual medications in the past? If yes, what and why? Has your child had any allergic reactions to Medications or drugs? Foods? Other? Has your child ever been hospitalized? If yes, when and where? Reason for hospitalization? Has your child had any surgery (operations)? Date(s) and Age(s)? For what reason(s)? Was general anesthesia used? Were there any complications? Are your child s immunizations current? Does your child have any history of the following diseases or conditions? Abuse (Physical or Sexual) Emotional Disability Nutritional Deficiency Anemia Fainting (often) Orthopedic Problems Arthritis Gastrointestinal Disorders Rheumatic Fever Asthma Hearing Loss: Type Transfusion of Blood Autism Heart Disease/Murmur Seizures Bleeding (prolonged) Hepatitis Sickle Cell Trait or Disease Brain Injury HIV Infection (AIDS) Snoring (Sleep Apnea) Cancer: Type Learning Disability Speech Prob.: Type Cerebral Palsy Kidney Disease Spina Bifida Cleft Lip/Palate Leukemia: Type Syndrome: Type Diabetes Mental Retardation Other Further Description or Remarks
4 MEDICAL HISTORY UPDATE (For future health changes) DATE NO CHANGE CHANGES PARENT SIGNATURE
5
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Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA
PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING
NEW PATIENT REGISTRATION
Welcome! NEW PATIENT REGISTRATION Thank you for choosing. We are committed to providing every adult and child with the highest quality oral healthcare in the most gentle, efficient manner possible. Remember,
LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION
A-02 form.patient.demographic.information Rev. (01/14) DATE: SIGNATURE: PHYSICIAN (PLEASE PRINT) LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION PATIENT'S FULL NAME ADDRESS APT. # CITY STATE
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.