HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING CONDITIONS?
IF YES, PLEASE ELABORATE
ABNORMAL BLEEDING
ADDADHD
ALLERGIES TO ANY DRUGS
ALLERGIES TO LATEX PRODUCTS
ANY HOSPITAL STAYS
ANY OPERATIONS
ASTHMA
AUTISM SPECTRUM DISORDER
CANCER
CARDIAC HEART CONDITIONS
CONGENITAL BIRTH DEFECTS
DIABETES
HEARING IMPAIRMENT
HEMOPHILIABLOOD DISORDERS
HEPATITIS
HIV + AIDS
KIDNEYLIVER CONDITIONS
PREGNANCY
REFLUXGI PROBLEMS
RHEUMATICSCARLET FEVER
SEIZURES
TUBERCULOSIS
DEVELOPMENTAL DELAYSDISABILITIES
NONE OF THE ABOVE
HEALTH HISTORY
IS THIS YOUR CHILD’S FIRST VISIT TO THE DENTIST? IF NOT, HOW LONG SINCE THE LAST VISIT?
PREVIOUS DENTIST’S NAME DATE OF LAST DENTAL XRAYS PREVIOUS INJURIES TO THE TEETH, FACE OR MOUTH?
YES NO
WHY DID YOU BRING YOUR CHILD TO THE DENTIST TODAY? IF YES, PLEASE EXPLAIN
DOES YOUR CHILD HAVE ANY OF THE FOLLOWING HABITS?
LIP SUCKING BITING
NURSING BOTTLE HABITS
NAIL BITING
CAVITIES
BLEEDING GUMS
DISCOLORED TEETH
MOUTH TRAUMABROKEN TOOTH
TEETH GRINDING
TOOTHACHE
SENSITIVITY TO HOTCOLD
BAD BREATH
THUMB FINGER SUCKING
PACIFIER USE
TOBACCO USE
DOES YOUR CHILD HAVE ANY CURRENT DENTAL ISSUES?
DOES YOUR CHILD BRUSH HISHER TEETH DAILY?
DOES YOUR CHILD FLOSS HISHER TEETH DAILY?
IF YES, PLEASE EXPLAIN
YES NO
YES NO
YES NO
HAS YOUR CHILD EVER HAD A SERIOUS OR DIFFICULT PROBLEM ASSOCIATED WITH PREVIOUS DENTAL WORK?
DENTAL HISTORY
YES NO
CHILD’S NAME LEGAL NICKNAME TODAY’S DATE
CHILD’S BIRTHDATE CHILD’S AGE CHILD’S FIRST LANGUAGEMALE FEMALE
CHILD’S HOME ADDRESS CITY STATE ZIP CODE
SCHOOL SPECIAL INTERESTS SIBLINGS WE TREAT
TELL US ABOUT YOUR CHILD
SUSAN FALLAHI, DDS - DIPLOMATE, AMERICAN BOARD OF PEDIATRIC DENTISTRY
3715 PRYTANIA STREET, SUITE 380 | NEW ORLEANS, LA 70115 | P (504) 896-7435 F (504) 896-7437
NEW PATIENT FORM
LIST ALL ALLERGIES YOUR CHILD CURRENTLY HAS LIST ALL MEDICATIONS YOUR CHILD IS CURRENTLY TAKING
CHILD’S PHYSICIAN IS YOUR CHILD CURRENTLY UNDER CARE OF A PHYSICIAN?
YOUR CHILD’S CURRENT PHYSICAL HEALTH
GOOD FAIR POORYES NO
NAME RELATIONSHIP DATE OF BIRTH
MARITAL STATUS SOCIAL SECURITY # DRIVERS LICENSE #SINGLE MARRIED DIVORCED WIDOWED
EMPLOYER WORK # CELL # EMAIL ADDRESS
ADDRESS CITY STATE ZIP
IMPORTANT NOTE: THE PARENT OR LEGAL GUARDIAN WHO ACCOMPANIES THE CHILD IS LEGALLY RESPONSIBLE FOR PAYMENT AT THE TIME OF SERVICE.
THE INFORMATION IN THIS SECTION APPLIES TO THE MAIN LEGAL CAREGIVER OF THE CHILDCHILDREN. IS THIS THE PERSON RESPONSIBLE FOR ACCOUNT?
PARENT/LEGAL GUARDIAN’S INFORMATION
YES NO
HOW DID YOU LEARN ABOUT OUR PRACTICE?
NAME RELATIONSHIP DATE OF BIRTH
MARITAL STATUS SOCIAL SECURITY # DRIVERS LICENSE #SINGLE MARRIED DIVORCED WIDOWED
EMPLOYER WORK # CELL # EMAIL ADDRESS
ADDRESS CITY STATE ZIP
IF DIFFERENT FROM ABOVE IS THIS THE PERSON RESPONSIBLE FOR ACCOUNT?SPOUSE OR EMERGENCY CONTACT’S INFORMATION
YES NO
POLICY OWNER’S NAME RELATIONSHIP DATE OF BIRTH
INSURANCE PROVIDER INSURANCE PHONE GROUP #
SOCIAL SECURITY NUMBER EMPLOYER
PRIMARY DENTAL INSURANCE
SIGNATURE OF PARENTGUARDIAN RELATIONSHIP DATE WITNESS
I UNDERSTAND THAT THE INFORMATION I HAVE GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT 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.
SIGNATURE