Child Teenager Health Form

NOTIFICATION

CHILD / TEENAGER HEALTH QUESTIONNAIRE
The date on this confidential questionnaire is essential to render the best professional care. We appreciate your co-operation in filling it out carefully, so that we will have accurate records.

PERSONAL INFORMATION

Patient's Last Name *

Given Names *

Sex *

Home Phone *

Apartment #

Address *

City *

Postal Code *

Date of Birth (mm/dd/yyyy) *

Are you a student? *

Name of School

Your Father's Given Name

His Occupation

Business Phone

His Employer

Business Address

Your Mother's Given Name

Her Occupation

Her Business Phone

Her Employer

Business Address

Name Of Family Member Responsible For Payment of Your Account

Whom May We Thank For Referring You To Our Office?

Do You have Dental Insurance Coverage?

Name Of Insuring Company

Group #

I.D. #

Physician or Pediatrician Name

Physician or Pediatrician Phone

HEALTH HISTORY

Have You Ever Had Any
Serious Operations? *
If YES, details
Serious Illness? *
If YES, details
Rheumatic Fever? *
If YES, details
Heart, or Blood Pressure Problems? *
If YES, details
Lung, or Breathing Problems? *
If YES, details
Stomach, or Intestinal Problems? *
If YES, details
Bleeding Tendencies? *
If YES, details
Anaemia? *
If YES, details
- Allergies
Hayfever? *
If YES, details
Asthma? *
If YES, details
Other? *
If YES, details
- Drug reactions or allergies to
Penicillin? *
If YES, details
Aspirin? *
If YES, details
Other Drugs? *
If YES, details
Approximately when did you have your last physical examination?
Aside from your regular checkups, are you now under treatment by a physician? *
If YES, details
What medications are you taking now?
Is there anything else that doctor should know about?
If YES, details
1. ARE YOU SEEKING TREATMENT for any particular reason and/or ROUTINE DENTAL CARE
2. Has your child had previous dental care *
If YES, when?
3. Has the child ever had an accident, injury or surgery about mouth?
If YES, details

OFFICE POLICY

Your appointment time will be reserved especially for you. if you are unable to keep the appointment we will require 24 hours notice, otherwise it will be necessary to charge for the time lost.
Office policy is that services are paid for at each visit as they are performed.
However in certain circumstances arrangements for payment may be made by consulting the business assistant.
Please indicate one of the following with a check mark:
1. I wish to pay each visit as the services are performed.
2. I wish to know the total fee for all the work to be done, as well as the number of appointments necessary, so that I can pay equal portions at each appointment.
3. I wish to discuss special arrangements for payment.
Date (mm/dd/yyyy) *
Parent/Guardian Name *
Parent/Guardian Signature (in the office)