Southern Indiana Pediatric Dentistry



Matthew L. Rasche, D.D.S., M.S.D. Board Certified in Pediatric DentistryNursing should be both enjoyable and pain freeMatthew L. Rasche, D.D.S., M.S.D.828 Auto Mall RoadBloomington, IN 47401812-333-5437, officeNewborn, Infants, Children, Adolescents, Special NeedsPatient’s Name: __________________________________Birth Date: _______________Today’s Date:__________Medical HistoryHas your child experienced any of the following problems or treatment?1. Received vitamin K injections?? Yes ? No2. Was your infant premature?? Yes ? No3. Does your infant have any heart disease?? Yes ? No4. Has your infant had any surgery?? Yes ? No If so, what? ______________________________________5. Has your infant experienced any of the following?_____ Poor latch_____ Falls asleep while attempting to nurse_____ Slides off the nipple when attempting to latch_____ Colic symptoms_____ Reflux symptoms_____ Poor weight gain_____ Gumming or chewing of your nipple when nursing_____ Unable to hold a pacifier in his/her mouth6. Is your infant taking any medications? Yes ? No If so, what? ______________________________________7. Has your infant had a prior surgery to correct to tongue or lip tie? If yes, when/where? _______________________________ _______________________________8. Birth weight: ________Present weight: ________Do you have any of the following signs or symptoms?_____ Creased, flattened or blanched nipples after nursing_____ Cracked, bruised or blistered nipples_____ Bleeding nipples_____ Severe pain when your infant attempts to latch_____ Poor or incomplete breast drainage_____ Infected nipples or breasts_____ Plugged ducts_____ MastitisPediatrician/Doctor: __________________________________Address: ____________________________________________City: _______________________________ State: ________Doctor’s Office Phone Number: __________________________Doctor’s Office Fax Number: __________________________Lactation Consultant: __________________________________LC Phone Number: ______________, Fax: _______________Address: ____________________________________________City: _______________________________ State: ________Referred By: _________________________________________Did you use the internet to locate my office?? Yes ? NoHave you visited our web site? ? Yes ? NoAdditional comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Thank you for choosing our office to assist your child’s needs!Like Us on FacebooksipediatricdentistrySIPD PATIENT INFORMATION AND HEALTH HISTORYCHILD’S NAME _____________________________________ NICKNAME: ____________ D.O.B.: __________ MALE / FEMALEHOME ADDRESS ____________________________________________ CITY: ____________________ STATE: _____ ZIP:________HOME PHONE _____________________________ E-Mail _________________________________________________________RESPONSIBLE PARTY (1): __________________________________________________ circle ( MOTHER / FATHER / GUARDIAN / OTHER ) RESPONSIBLE PARTY (2): __________________________________________________ circle ( MOTHER / FATHER / GUARDIAN / OTHER ) RESPONSIBLE PARTY (1) WORK PHONE_______________________ CELL PHONE ______________________ May we Text? Y / NEMPLOYER: _____________________________________________ OCCUPATION: ________________________________________RESPONSIBLE PARTY (2) WORK PHONE _______________________ CELL PHONE _______________________ May we Text? Y / NEMPLOYER: _____________________________________________ OCCUPATION: ________________________________________EMERGENCY CONTACT (other than parent/guardian) _________________________________________________________________RELATIONSHIP TO CHILD ___________________________________ EMERGENCY PHONE _________________________________OTHER SIBLINGS: _____________________________________________________ HAVE THEY BEEN SEEN IN OUR OFFICE: YES / NODENTAL INSURANCE:PRIMARY CARRIER: ________________________________________ SUBSCRIBER:_________________________________________SSN and/or ID Number: ____________________________________ D.O.B.: ____________________________________________SECONDARY CARRIER: ______________________________________ SUBSCRIBER:________________________________________SSN and/or ID Number: _____________________________________ D.O.B.: ____________________________________________MEDICAL INFORMATION:Child’s Medical Physician/Pediatrician ______________________________________ Location of Office ______________________Please list any current ALLERGIES ________________________________________________________________________________Please list any current MEDICATIONS _____________________________________________________________________________Does your child have: (circle any that apply) asthma, heart problems, difficulty hearing, speech impediment, developmental delays, any medical or emotional disturbance, cerebral palsy, liver or kidney disease, seizures, convulsions, or fainting spells, diabetes, hepatitis, sickle cell anemia, tuberculosis, bleeding problems, immune system disorders?Medical Diagnosis _____________________________________________________________________________________________SBE (pre-meds) required: YES / NOIf so, pharmacy name and phone number: _____________________________________If Asthma, has your child been seen in the emergency room? YES / NO When? _____________________________________What triggered reaction? _______________________________________ Inhaler needed? YES / NOImmunization status: Current / Past Due / Other: _________________________________________________________________Hospitalizations/Surgeries: ______________________________________________________________________________________Date of Last Dental Exam: ____________ Dentist: ______________________________________ Location: ___________________Has there been any injury to the teeth, head or neck since the patient’s last cleaning and is there any condition/problem you wish to bring to the doctor’s attention? YES / NOPlease explain ________________________________________________________________________________________________Whom may we thank for referring you to our office? ________________________________________________________________DATE: _______________________ PARENT/GUARDIAN SIGNATURE __________________________________________________INITIAL DATE: ____________________ DOCTOR’S SIGNATURE ______________________________________________________----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- SEMI-ANNUAL REVIEW of Medical-Dental History: If above history remains essentially unchanged, sign below.A NEW HISTORY FORM MUST BE COMPLETED EVERY TWO YEARS OR IF ANY CHANGES HAVE OCCURRED.DATE: ____________PARENT/GUARDIAN: ____________________________________ DOCTOR:________________________DATE: ____________PARENT/GUARDIAN: ____________________________________ DOCTOR:_______________________DATE: ____________PARENT/GUARDIAN: ____________________________________ DOCTOR:_______________________ Southern Indiana Pediatric Dentistry 828 Auto Mall Road Bloomington, IN 47401 ................
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