PATIENT INFORMATION FORM
Parents of children: The information requested is very important. In order for your child to receive dental care
provided by Miles for Smiles, you will need to complete this form for you child. This information form becomes
part of our permanent record and will be held in strict confidence.
Please circle YES or NO, where indicated. If you are unable to complete this form by yourself, please ask for
assistance.
Thank you!
MoHealthNet/Medicaid No.______________________
Please make a copy of the card and return with this form
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Date:___________________________
School:__________________________
Name of Patient____________________________________________________________________________
Name patient wishes to be called_______________________________________________________________
Date of Birth___________________________ Place of Birth_______________________________________
Age of Patient____________ year __________ months
Sex: Male
Female
What is the patient’s: Height?__________ Weight _____________
Home address: __________________________________________________________________________
__________________________________________________________________________
Telephone Number: Home ___________________________ Business ______________________________
Does the child have any private dental insurance?
YES NO
Does you child have Medicaid/MC+
YES NO
Medicaid Number: ___________________________ MC+ number:_________________________________
Is your child eligible for free/reduces school lunches?
YES NO
Has your child seen a dentist before? YES NO If yes, date of last visit _____________________________
Would you be willing to bring your child to school early for treatment?
YES
NO
Would you be willing to for your child to stay after school for treatment?
YES
NO
 If yes, you must be there with your child and able to take them home!
Please check the reason (s) for seeking dental care?
_____ Routine checkup
_____Appearance of teeth
_____ First visit
_____ Swelling of face
_____ Toothache
_____ Crowding of teeth
_____ Accident to teeth
_____ Bleeding around teeth
_____ Other (specify) ___________________________________________________________________________
DENTAL AND MEDICAL HISTORY: (please circle YES or NO where indicated)
1. Has the child had an unusual or unpleasant experience in a dental or medical office?
2. Has the child ever had any injuries to the face, mouth or teeth?
3. Has the child ever has a toothache?
4. Does the child have any oral habits such as thumb sucking?
5. Is the child presently in good health?
6. Is the child’s immunization records up to date?
7. Were there any problems during pregnancy, delivery or during the child first year?
8. Does your child take any fluoride supplements?
9. Does your child have a history of allergies?
10. Tylenol for children may be given by school nurses for discomfort?
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
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MEDICAL HISTORY
Is your child under a physician’s care now? YES or NO If yes, please explain: _____________________________
Has your child ever been hospitalized or had major operations? YES or NO
If yes, please explain: ________________________________
Is your child taking any medications, pills, or drugs? YES or NO If yes, please explain: ______________________
Does your child take or has taken Phen –Fed or Redux? YES or NO If yes, please explain: ________________
Is your child on a special diet? YES or NO If yes, please explain: ________________________________________
Does your child use tobacco? YES or NO If yes, please explain: ________________________________________
Does your child use controlled substances? YES or NO If yes, please explain: _____________________________
Women: Are you _____ Pregnant/Trying to get pregnant? _____ Nursing? _____ Taking oral contraceptives?
Are you allergic to the following?
_____ Aspirin
_____ Penicillin
_____ Local
_____ Anesthetics
_____ Codeine
_____ Acrylic
_____Metal
_____Latex
_____ other if yes, what: __________________________________________
Does your child have any heart problems that require antibiotics before dental treatment? Yes No
Does your child have or had any of the following?
__ AIDS/HIV Positive __ Scarlet Fever
__ Irregular Heartbeat
__ Alzheimer’s
__ Shingles
__ Kidney Problems
__ Anaphylaxis
__ Sickle Cell Disease
__ Leukemia
__ Anemia
__ Sinus Trouble
__ Liver Disease
__ Angina
__ Spina Bifida
__ Low Blood Pressure
__ Arthritous / Gout
__ Stomach/Intestinal Disease__ Lung Disease
__ Artificial heart valve __ Stroke
__ Mitral Valve Prolapse
__ Artificial Joints
__ Swelling or Limbs
__ Pain in Jaw Joints
__ Asthma
___Thyroid Disease
__ Parathyroid Disease
__ Blood Disease
__ Tonsillitis
__ Psychiatric Care
__ Blood Transfusion
___Tuberculosis
__ Radiation Treatment
__ Breathing Problems
__ Tumor or growths
__ Recent Weight Loss
__ Bruise easily
__ Ulcers
__ Renal Dialysis
__ Cancer
__ Venereal Disease
__ Rheumatic Fever
__ Chemotherapy
___ Yellow Jaundice
__ Rheumatism
Has your child ever had any serious illness not listed above? __ YES __ NO
__ Chest Pains
__ Cold Sores
__ Congenital Heart Disorder
__ Convulsions
__ Cortisone Medicine
__ Diabetes
__ Drug Addiction
__ Easily Winded
__ Emphysema
__ Epilepsy or seizures
__ Excessive bleeding
__ Excessive thirst
__ Fainting Spells
__ Frequent cough
__ Frequent Diarrhea
__ Frequent Headaches
__ Genital Herpes
__ Glaucoma
__ Hay Fever
__ Heart Attack / Failure
__ Heart Murmur
__ Heart Pace Maker
__ Heart Trouble / Disease
__ Hemophilia
__ Hepatitis A
__ Hepatitis B or C
__ Herpes
__ High Blood Pressure
__ Hives or Rash
__ Hypoglycemia
If yes, explain ________________________
CONSENT AND AGREEMENT
Our staff will answer any questions about consent and agreement form that are not clear.
I hereby give consent to the Dentist of Miles for Smiles and dental auxiliaries working under the dentist’s
supervision to perform on ________________ my son/daughter ______________ my ward those procedures and
treatment including anesthesia and in the administration of drugs common to dental practice. I am aware that the
risks are essentially the same as those procedures performed in a hospital or private dentist’s office (for example:
possible allergic reactions to anesthetic or possible accidental cuts or abrasions). Further, I certify that I
understand and agree to the conditions set forth above. I also understand I am free to ask any questions regarding
the procedure and risk involved and that I have received a copy of the privacy policy.
I also give permission for Miles for Smiles to use photos of my child, in publicity project for the projects, such as
marketing brochures, an annual report or news article. This consent will be in effect for the school
Year ___________ to ___________.
Thank you
Signature of Parent/Guardian: ___________________________________________
Relationship to patient:_________________________________________________