Patient and Family Information | Pediatric Dentistry at North Bethesda

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If you would prefer printing out our form and bringing it into our office, please download the two PDF files below. You can then print them and bring them into our office.

PATIENT FORM (PDF)

PATIENT INFORMATION

Last	First	Middle Initial	Nickname
Sex: MF	Birthdate	Age	Soc. Sec #
Address	Apt #	City	State	Zip
School	Grade	Hobbies, Sports, etc.
Whom may we thank for referring you?

PARENTS INFORMATION

Parent

Relation: Parent/FatherStep ParentGuardian
NAME Last	First	Middle Initial	Marital Status
Same Address as Child: Yes
Address	Apt #	City	State	Zip
Home Phone	Cell Phone	Work Phone
Email
Soc. Sec #	Birthdate
Employer	Occupation

Parent

Relation: Parent/MotherStep ParentGuardian
NAME Last	First	Middle Initial	Marital Status
Same Address as Child: Yes
Address	Apt #	City	State	Zip
Home Phone	Cell Phone	Work Phone
Email
Soc. Sec #	Birthdate
Employer	Occupation

DENTAL INSURANCE INFORMATION (Primary Carrier)

Insurance Name	Insurance Phone	Insurance Address
Insured's Name	Birthdate	Soc. Sec #
Member ID
Insured's Employer
I certify that my child is covered by the above insurance co. and I assign all insurance benefit otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductible that my insurance does not cover. I hereby authorize that dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Name	Date

If you have additional dental insurance coverage, complete this for the secondary carrier.

Is child covered by additional insurance? YESNO
Insurance Name	Insurance Phone	Insurance Address
Insured's Name	Birthdate	Soc. Sec #
Member ID
Insured's Employer
I certify that my child is covered by the above insurance co. and I assign all insurance benefit otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductible that my insurance does not cover. I hereby authorize that dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Name	Date

It is important that we know about your child's Medical and Dental History. These facts have a direct bearing on your child's Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

Is this the child's first visit to dentist?	YESNO
Former Dentist	Address	Phone
Reason for the child's visit today?
Is the child currently in pain?	YESNO
Does the child require antibiotics before dental treatment?	YESNO
Has the child ever had a serious/difficult problem associated with previous dental work?	YESNO
Is the child's water flouridated?	YESNO
Is the child taking flouride supplement?	YESNO
Does your child get brushed his/her teeth daily?
Does your child get flossed his/her teeth daily?
Who brushes and flosses his/her teeth?
Date of last dental care
Date of last xrays
How often does your child floss?
Does your child experience pain or discomfort in the jaw joint?	YESNO
Has your child ever experienced a mouth or chin injury?	YESNO
Does your child have speech problems?	YESNO
Has your child ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?	YESNO
Other information about your child's dental health or previous treatment

Child's Physician		Phone
Date of last visit
Please describe the child's current physical health. GoodFairPoor
List medications your child is taking, if any
List drug allergies, if any
Has your child had any serious illnesses or operations?		YESNO
If yes, please describe
Is your child currently under physician care?		YESNO
If yes, please describe
Has your child ever had a blood transfusion?		YESNO
If yes, please give approximate date
Has your child ever taken Fen-Phen/Redux?		YESNO
PLEASE CHECK YES OR NO OF THE FOLLOWING WHICH YOUR CHILD HAS HAD OR PRESENTLY HAS:
ADD/ADHD		YESNO
AIDS/HIV Pos.		YESNO
Anemia		YESNO
Any hospital stays/operations?		YESNO
Artificial bone/joints/valves		YESNO
Asthma		YESNO
Atopic (allergy prone)		YESNO
Blood Disease		YESNO
Cancer		YESNO
Chicken Pox		YESNO
Congenital Heart Disease		YESNO
Convulsions/epilepsy		YESNO
Cough (persistent)		YESNO
Cough up blood		YESNO
Diabetes		YESNO
Fainting		YESNO
Food allergies		YESNO
Handicapped/disabilities		YESNO
Headaches		YESNO
Hearing Impairment		YESNO
Heart murmur		YESNO
Heart problems		YESNO
If yes, please describe:
Hemophilia (abnormal bleeding)		YESNO
Hepatitis		YESNO
High Blood Pressure		YESNO
Hives		YESNO
Immunizations current		YESNO
Kidney disease or malfunction		YESNO
Liver disease		YESNO
Low Blood Pressure		YESNO
Lupus		YESNO
Material allergies (latex, wool, metal, chemicals)		YESNO
Measles		YESNO
Mitral valve prolapse		YESNO
Mononucleosis		YESNO
Prosthetics		YESNO
Exposed to HIV, but Neg.		YESNO
Respiratory disease		YESNO
Rheumatic/scarlet fever		YESNO
Shortness of breath		YESNO
Sinus problems		YESNO
Skin rash		YESNO
Spina Bifida		YESNO
Thyroid disease or malfunction		YESNO
Tonsilitis		YESNO
Tuberculosis		YESNO
Anything you would like to discuss with the doctor in private?		YESNO
Does/did your child experience any of the following?
Breast Fed		YESNO
Chewing on objects		YESNO
Clenching/grinding teeth		YESNO
Lip sucking/biting		YESNO
Mouth breather		YESNO
Nail biting		YESNO
Nursing bottle habit		YESNO
Speech problem		YESNO
Thumb/finger sucking		YESNO
Tongue cheek biting		YESNO
Tongue thrust		YESNO
Used pacifier		YESNO
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and 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.
Name	Date

PATIENT INFORMATION

PARENTS INFORMATION

Parent

Parent

DENTAL INSURANCE INFORMATION (Primary Carrier)

If you have additional dental insurance coverage, complete this for the secondary carrier.

It is important that we know about your child's Medical and Dental History. These facts have a direct bearing on your child's Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

DENTAL HISTORY

MEDICAL HISTORY

PLEASE CHECK YES OR NO OF THE FOLLOWING WHICH YOUR CHILD HAS HAD OR PRESENTLY HAS: