DavidLRothmanDDS.com - Child's Registration and History

David L. Rothman, D.D.S.
Pediatric Dentistry

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Child's Registration and History
Please complete, print out, and sign

Child's Name: Nickname:

Sex: Male Female Birthdate: Age:
School:

Is this your child's first dental visit? Yes No Is this an emergency visit? Yes No

If no, name of former dentist? Date of last visit:
Purpose:

Have any other children in your family been a patient in this office before? Yes No
If yes, names:

Has your child had any bad dental experiences? Yes No
If yes, explain:

Please check any of the following which may describe your child:

Outgoing	Shy	Stubborn	Anxious	Frightened	Defiant
Suspicious	Moody	High Strung	Regular Kid	Friendly	Cooperative

Name of child's pet:

Favorite Interest:

Favorite Sport:

How do you expect your child to react to his/her visit today?
Excellent Good Fair Poor Don't Know

How may we help to make this a positive experience for your child?

Name of family dentist:

Whom may we thank for referring you to our office?

Child's Pediatrician: Date of last physical:
Address: Phone: () -

My child is foster/adopted and has lived with me for years.

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Is your child in good health? Yes No

Are your child's immunizations up to date? Yes No

Is your child being treated for any condition presently? Yes No
If yes, explain:

Has your child ever been hospitalized or had surgery? Yes No
If yes, explain:

Does your child have any allergies or reactions to any medications? Yes No
If yes, explain:

Does your child have any allergies to the following? pollen food food dyes dust other

Has your child ever been diagnosed as having any of the following conditions?

Yes No Acid Reflux	Yes No Excessive Bleeding Problem
Yes No ADD/ADHD	Yes No Excessive Gagging
Yes No AIDS	Yes No Fainting or Dizziness
Yes No Allergies to Medication	Yes No Growth and Development Problems
Yes No Anemia	Yes No Hearing/Speech Problems
Yes No Asthma	Yes No Heart Problems
Yes No Autism	Yes No Hemophilia
Yes No Bladder Conditions	Yes No Hepatitis or Liver Disease
Yes No Blood Transfusions	Yes No Kidney Disease
Yes No Birth Defects	Yes No Leukemia
Yes No Bone or Joint Problems	Yes No Mental/Emotional Disturbances
Yes No Brain Injury	Yes No Nutritional Deficiency
Yes No Bruising Easily	Yes No Oral Ulcers
Yes No Cancer or Malignancies	Yes No Orthopedic Problems
Yes No Cerebral Palsy	Yes No Premature Birth
Yes No Child Abuse	Yes No Rheumatic Fever
Yes No Chronic Adenoid\ Tonsil Infection	Yes No Scoliosis/Spine Problems
Yes No Chronic Headaches	Yes No Sickle Cell Anemia
Yes No Chronic Ear Infections	Yes No Sleep Disorder/Obstructive Sleep Apnea
Yes No Cleft Lip/Palate	Yes No Spina Bifida
Yes No Convulsions/Seizures	Yes No Syndrome
Yes No Diabetes	Yes No Tuberculosis
Yes No Epilepsy	Other
Yes No Eye Problem

Please describe any current or pending medical treatment including drugs, recent injuries or any other information I should be aware of that has not been covered:

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Dental Information

Was your child bottle fed? Yes No If yes, until what age?

Was your child breast fed? Yes No If yes, until what age?

Has your child had any injuries to his teeth, mouth, head or jaw?

Does your child brush daily?

Does an adult assist with the brushing?

Does your child floss daily?

Does an adult assist with the flossing?

Does your child have any of the following oral habits:

Finger Sucking	Pacifier	Lip Sucking	Teeth Grinding
Thumb Sucking	Tongue Thrusting	Mouth Breather	Other

Does your child receive fluoride in any of the following forms:

Vitamins	Water Supply	Tablets/Drops
Dosage: mg/day	Toothpaste	Rinse/Gel

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General Information

Parent Full Name:	Parent Full Name:
Relationship:	Relationship:
Social Security Number: --	Social Security Number: --
Birthdate:	Birthdate:
Address:	Address:
City:	City:
State: Zip:	State: Zip:
Phone: () -	Phone: () -
Email:	Email:
Employed By:	Employed By:
Occupation:	Occupation:
Business Phone: () -	Business Phone: () -
Child lives with: Both parents Mother Father Other

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For Patients Covered By Insurance

Primary Carrier	Secondary Carrier
Subscriber Name	Subscriber Name:
Insurance Company, Address, and Phone:	Insurance Company, Address, and Phone:



Employer Name, Address, and Phone:	Employer Name, Address, and Phone:



Group/Policy Number:	Group/Policy Number:
How long have you had this coverage? yrs	How long have you had this coverage? yrs

In order to comply with most insurance companies, we ask that you sign below so that we may keep your signature on file.

I have reviewed the following treatment plan. I authorize the release of any information relating to this claim. I authorize payment of the dental benefits directly to the dentist.	I have reviewed the following treatment plan. I authorize the release of any information relating to this claim. I authorize payment of the dental benefits directly to the dentist.
___________________________________________ Signature of patient or parent (if minor)	___________________________________________ Signature of patient or parent (if minor)