Biographical Child Form

Biographical (Child)

Patient Name:

Age:

Date of Birth:

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

Locking Jaw

Teeth or Jaw injuries/accidents

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?

Hepatitis?

Abnormal heart conditions?

Diabetes?

Abnormal bleeding from cuts?

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?

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?

Insurance Information

Insurance company:

Name of Holder:

Birth Date::

Policy/Group #:

Certificate/ID #:

Employer:

First Nations Inuit Health Benefits

Treaty #:

Band Name and Phone #: