SMILES FOR MILES PEDIATRIC DENTISTRY Dr. Mal Azar, D.M.D ...

SMILES FOR MILES PEDIATRIC DENTISTRY

Dr. Mal Azar, D.M.D Board Certified Pediatric Dentist

Today's Date: ____________________ Reason For Visit: ______________________________________

In order to ensure that your child receives the best care at our practice, we ask you to carefully complete both pages of this form. It is important for us to know about all parts of your child's health history. This form is completely confidential, and will be used only for dental and medical reasons.

Patient Information:

Full Name (First Name, Middle Name, Last Name): ________________________________________________________________________________________________

Nickname: _________________________________________

Fun Facts About Your Child (Interests/Hobbies/Favorite Color):_________________________________________________________________________________

Age: _________

Date of Birth: _____________________

Gender: M [ ] F [ ]

Address: _________________________________________________________________________________________City: ___________________ Zip Code: _________________

Person Responsible for Appointments/Finances (Relationship): _____________________________________________________________________________________________

Preferred Method of Contact: Text message [ ] E-mail [ ] Cell phone [ ] Home Phone [ ] Specific Note: ___________________________________

Emergency contact (Name, Relationship, Number): _______________________________________________________________________________________________

Whom may we thank for referring you? (Website, Patient (inc. name), Doctor (inc name), etc):______________________________________________

Legal Guardian Information:

Mother's Name/Legal Guardian's Name: ______________________________________________________ Occupation: _________________________________________ Address (if different from above): ______________________________________________________________ Home Phone: ________________________________________ Work Phone: ________________________________________ Cell Phone: __________________________________________ Email: ___________________________________________________

Father's Name/Legal Guardian's Name: ______________________________________________________ Occupation: _________________________________________ Address (if different from above): ______________________________________________________________ Home Phone: ________________________________________ Work Phone: ________________________________________ Cell Phone: __________________________________________ Email: ___________________________________________________

Health Care Providers:

Physician's Name/Office Name, Number, Address: _______________________________________________________________________________________________________________________________________________________ Previous Dentist's Name/Office Name, Number, Address: ________________________________________________________________________________________________________________________________________________________

Medical History:

Please review carefully and check the most relevant condition below: If healthy- can place cross across section

General conditions: o Arthritis o Asthma Asthma Attack/When?_____________

o Diabetes o Down Syndrome o Gastrointestinal disorders

o Heart disease o Heart murmur o Kidney disease

o Rheumatic fever Behavior/Learning:

o ADHD o Anxiousness/Nervousness

o Autism o Behavior issues:

Type________________________

o Learning disability: Type_______________________

o Psychiatric disorder:

Type______________________ Other

o Cancer: Type _____________

o Leukemia: Type ___________ o Fainting/headaches (often) o Sleep apnea

o Snoring o Other- Describe on page backside

Developmental Conditions: o Premature

o Brain injury o Cerebral palsy o Cleft lip/palate

o Developmental Delay o Feeding/Eating problems o Growth problems

o Hearing loss: Type ______________________________________ o Neuromuscular defect o Orthopedic problems o Seizures: Type______________Last Seizure: _____________

o Speech problem: Type _________________________________ o Spina bifida Hematological (Blood-related) :

o Anemia: Type ___________________________________________ o Bleeding (prolonged) o Hemophilia

o Sickle cell traitSickle cell disease o Transfusion of blood Substance use/Abuse

o Drug use : Type (alcohol, tobacco, etc) ________________ o Abuse (physical or sexual) Infectious

o Hepatitis o HIV infection (AIDS) o Tuberculosis

Immunizations Up to Date: Yes/No

If not, why: ________________________________________________________

Hospitalizations? Yes/No If so, date/reason for visit: ___________________________________________________

Surgeries? Yes/No

If so, date/type: _______________________________________________________________

Current Medications: _______________________________________________________________________________________________________________________________

ALL Allergies (inc.environmental, food, meds):____________________________________________________________________________________________________

Dental History:Please check as indicated or circle "Yes/No"

Date of Last Dental Visit: _______________________Reason for Visit: ______________________________ Dentist Name: _________________________________ Was he/she a pediatric dentist? Yes/No History of Treatment: *check below*

Cleanings[ ]Fluoride varnish [ ]Xrays [ ] Local Anesthetic [ ] Dental Work (including fillings, crowns, and/or extractions) [ ] Treatment under general anesthesia [ ] Treatment under Nitrous Oxide[ ]

Any dental -specific allergies (Latex, Local Anesthetic)?: Yes/No Describe: _____________________________________________

Any History of Dental Pain/Toothache/Abscess?: Yes/ No Describe:___________________________________________

Any History of Jaw Pain/Popping/Clicking? Yes/No

Any past Head/Mouth/Tooth injury? Yes/No Describe:______________________________________________

Any habits (tooth grinding, pacifier, thumbsucking, nail biting, etc)? : ___________________________________________________________________________________________________ Does your child take fluoride supplements? Yes/No

Diet: Does you child snack frequently? Yes/No What most frequent snacks does he/she eat?

o Fruits/Veggies? o Processed Snacks- Gold fish,

cookies, crackers, pretzels o Flavored milks, yogurts o Juices o Fruit Snacks Does he/she take gummy vitamins? Yes/No

Oral Hygiene: Does your child brush? Yes/No

o Times per day: ______ o With help: Yes/No Type of toothpaste: _____________________ Floss? Yes/No

Infant History: Bottle to Bed? Yes/No Bottle contains: _______________________ Currently Breast-Feeding? Yes/No How many times/when:

APPOINTMENT POLICY: PLEASE NOTIFY THIS OFFICE 24 HOURS PRIOR TO AN APPOINTMENT IF YOU MUST CANCEL IT. THIS OFFICE RESERVES THE RIGHT TO CHARGE A CANCELLATION FEE.

Smiles For Miles Pediatric Dentistry follows Federal and State law by complying with HIPPA standards. I certify that I have read and understood the above. I understand that the information that I have given is correct to the best of my knowledge. I will not hold Smiles For Miles Pediatric Dentistry or staff responsible for any errors/omissions, I may have made in the completion of this form. I also authorize the Doctor's and staff of Smiles For Miles Pediatric Dentistry to perform the necessary dental services that they have explained to me.

Signature of Parent/Guardian _______________________________________ Date ____________ Doctor's Signature______________________________________ Date____________

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