Biographical (Child)
Patient Name:
Age:
Date of Birth:
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Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
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01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
Sex ( Circle one ):
M
F
Email:
Mother: Name:
Address:
City:
Prov:
Postal Code:
Phone: Home:
Work:
Cell:
Father: Name:
Address:
City:
Prov:
Postal Code:
Phone: Home:
Work:
Cell:
Who will be the primary contact? (circle on if applicable)
Mom
Dad
Dentist Name:
Date of last visit:
Have you ever had any of the following?
Clicking Jaw Joint
Yes
No
Locking Jaw
Yes
No
Teeth or Jaw injuries/accidents
Yes
No
Do you have any habits such as biting nails, sucking your thumb, etc? If yes please specify:
Have you ever had any of the following?
Rheumatic Fever?
Yes
No
Hepatitis?
Yes
No
Abnormal heart conditions?
Yes
No
Diabetes?
Yes
No
Abnormal bleeding from cuts?
Yes
No
Allergies? Please Specify:
Have you ever had any medical conditions in the past? If yes, please specify:
Are you currently taking any prescription or non-prescription medications?
Yes
No
If yes, please specify:
How did you find out about our office?
Dentist
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Friend
Other:
Has anyone in your family had braces in this office? If yes, please name:
What concerns you the most about your teeth?
First Nations Inuit Health Benefits
Treaty #:
Band Name and Phone #: