Home | Patient Information Patient Information Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 2Name *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMaleFemaleNicknameAddressAddress Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address (if different from above)Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact Info for Legal Guardian (if not bio parents)Whom may we thank for referring you to our office? Please list other members of your immediate family who are patients at Kids Dental ExpertsInterests/hobbiesPARENT/GUARDIAN INFORMATIONMother's Name *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell Phone *Address (if different than patient)Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security NumberEmployer & PositionEmailWork PhoneFather's Name *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell Phone *Address (if different than patient)Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security Number Employer & PositionEmailWork PhoneBiological Parents’ Marital Status MarriedDivorcedNever MarriedWidowedSeperatedStep-Mother's NameDate of Birth MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell Phone Address (if different than patient)Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security Number Employer & PositionEmailWork PhoneStep-Father's NameDate of Birth MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell Phone Address (if different than patient)Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security NumberEmployer & PositionEmail Work PhoneNextMEDICAL HISTORYChild’s Physician *PhoneDate of last visitMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is your child being seen by healthcare providers for anything other than routine visits? YesNoExplainIs your child receiving any medications? YesNoMedicine, Dosage, Reason for takingHas your child ever been hospitalized?YesNoDetailsAny excessive or prolonged bleeding when cut? YesNoExplainPlease list any surgeries: Has the child or anyone in the family had complications with anesthesia? YesNoIs your child allergic to:PenicillinLatexLocal AnestheticOther Meds, Foods, Products-List BelowAllergic toReactionAllergic toReactionAllergic toReaction *Please describe any emotional concerns or special needs: Please check if child has a history of difficulty with any of the following: ADD (Attention Deficit Disorder)ADHD (Attention Deficit Hyperactive Disorder)AIDS/HIVAnemiaAnorexia/BulimiaArthritisAutismBladderBlood pressure concernsBlood transfusionBruising easilyChicken PoxDepressionDiabetesDown SyndromeEpilepsy/SeizuresFainting spellsHearingHeart condition (may require antibiotic before visits)Hepatitis A B CHives or Skin RashLiver diseaseMalignanciesMeaslesMononucleosisMumpsNervousnessPersistent coughRheumatic feverSurgery or radiation head/neck conditionThyroid issuesTuberculosisVenereal diseaseNotesNotesDental HistoryLast office seen atDate of last dental visitMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of serviceHas your child complained about dental problems? YesNoExplainMost important dental concernAny unhappy dental experiences? YesNoExplain Any injuries to the mouth, teeth or head?YesNoExplain How does your child feel about dental visits? Please check the following to indicate “Yes” regarding this patient.aphthous ulcers (canker sores)breath odorchewing tobaccoearachesfinger suckingfrequent soda consumptionfrequent vomitingheadachesherpetic lesions (cold sores)jaw clicks/pops/grindslip biting or suckingmouth breathingnail bitingnursing or bottle habitneck painorthodontic concerns (crooked teeth or bite)pacifier habitsmokingsnoringspeech impairedstrong gag reflexteeth grinding or clenchingthumb suckingGreen Bay city water is fluoridated. Is there fluoride in your water supply? YesNoUnsureIs a fluoride toothpaste/rinse used? YesNoUnsureAre teeth brushed daily? YesNoParents brushChild brushesAre teeth flossed daily? YesNoParents flossChild flossesHow often?How often? Is there history of decay in the familyNoYes, mom’s sideYes, dad’s sideYes, siblingsUnder 18 monthsIs your child under 18 months?YesNoTermFull TermPrematureDid the child have any of the following during the 1st few weeks of life? JaundiceBreathing troubleHigh feversIntubationFeeding issuesOther serious illnessDid the mother experience any of the below during pregnancy?Sever morning sicknessFrequent feversPhysical traumaMedicationsDetails on complications during pregnancy, delivery, or infant’s early life: Check all that apply:MedicationsBreast fedBreast milkBottle fedFormulaCurrently breast/bottle feedingCow’s milkIs fed at bedtimeWeaned at how many months?If applicableI have completed the requested information on this form to the best of my knowledge.Signature * Clear Signature Relationship to patientDateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit
