Angelina Ring, DDS, Inc.
Health History Form
Patient Information
_______________________
Child’s First Name
_______________
________________________
Middle
Gender: Male [ ] Female [ ]
____/____/________
Last
Birth Date
Purpose of visit: _______________________ Concerns: _______________________________________________ Last dental visit: ____________________
Name and age of brothers and sisters: _________________________________________________________________________________________________
Is your child adopted? Yes [ ] No [ ]
Child’s interests: _______________________________________________________________________________ Name of pet: _______________________
Does your child have any special needs?_______________________________________________________________________________________________
Child’s learning: Slow [ ] Average [ ] Accelerated [ ]
Child’s previous dentist: _________________________________________________Family Dentist: _____________________________________________
Orthodontist:____________________________________ Who may we thank for referring you to us?_____________________________________________
Health History
Reviewed: ________
Child’s Pediatrician: _______________________________________ ___________________ _______________
Name
Phone
Date: ____________
Last Physical
Is your child under a physicians care now? Yes [ ] No [ ] If Yes, Reason: __________________________________________________________________
Pharmacy:__________________________________________
___________________________________________________
Name
Address
Has your child received all immunizations? Yes [ ] No [ ]
Is your child taking medications or drugs? Yes [ ] No [ ]
If Yes, What kind? ________________________________________________ Reason: _______________________________________________________
Has your child ever been hospitalized? Yes [ ] No [ ] If Yes, Reason: ____________________________________________________________________
Is your child allergic to any medications? Yes [ ] No [ ] If Yes, Please list: _________________________________________________________________
_______________________________________________________________________________________________________________________________
Does your child have an allergic reaction to:
[ ] eggs
[ ] latex [ ] soy [ ] dust [ ] foods
Does your child have any of these habits:
[ ] finger/thumb sucking [ ] pacifier [ ] lip sucking
Has your child had any injuries to teeth, mouth or head?
[ ] animals
[ ] pollen
[ ] lip sucking
[ ] snoring
[ ] other :______________________________________
[ ] teeth grinding
Yes [ ] No [ ] If Yes, Describe: _____________________________________________________
Has your child had a history or difficulty with any of the following?
Yes [ ] No [ ] Premature Birth
Yes [ ] No [ ] Earaches
Yes [ ] No [ ] Speech Disorder
Yes [ ] No [ ]Nosebleeds
Yes [ ] No [ ] Heart
Yes [ ] No [ ] Kidney
Yes [ ] No [ ] Hearing
Yes [ ] No [ ] Asthma
Yes [ ] No [ ] Seizures
Yes [ ] No [ ] Bleeding
Yes [ ] No [ ] Brain injury
Yes [ ] No [ ] Liver
Yes [ ] No [ ] Immune disorder
Yes [ ] No [ ] Cerebral Palsy
Yes [ ] No [ ] Bruising
Yes [ ] No [ ] Brain
Yes [ ] No [ ] Allergy to medication
Yes [ ] No [ ] Anemia
Yes [ ] No [ ] Bladder
Yes [ ] No [ ] Rheumatic fever
Yes [ ] No [ ] Diabetes
Yes [ ] No [ ] Motion sickness
Yes [ ] No [ ] Fainting or dizziness Yes [ ] No [ ] Tuberculosis
Yes [ ] No [ ] Hepatitis
Yes [ ] No [ ] Cancer
Yes [ ] No [ ] Delayed Development
Yes [ ] No [ ] Autism
Yes [ ] No [ ] ADD/ ADHD
Yes [ ] No [ ] Emotional or school problems
Any medical condition not mentioned above:___________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
How may we help make this visit a positive experience for your child? _________________________________________________________________________
__________________________________________________________________________________________________________________________________
Notice of Privacy Practices
I have received a copy of Napa Pediatric Dentistry’s Notice of Privacy Practices and Dental Materials Fact Sheet.
You may refuse to sign this acknowledgement.
__________________________________________
_____________________________
Signature
3425 Valle Verde Dr. Napa, CA 94558
Print Name
|
T: (707) 265-8389
|
F: (707) 265-8444
______________________________
Relationship to Patient
|
frontdesk@drangie.com |
__________________
Date
www.napapediatricdentistry.com
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Angelina Ring, DDS, Inc.
Health History Form
General Information
Parent 1 : _______________________________________
______-_____-________
Full Name
__________________ _________________ ____/____/_______
Social Security Number
Parent 2: _______________________________________
______-_____-________
Full Name
Phone
Cell
Birth Date
__________________ _________________ ____/____/________
Social Security Number
Phone
Cell
Birth Date
Marital Status: Single [ ] Married [ ] Divorced [ ]
Child resides with: Both parents [ ] Parent 1 [ ] Parent 2 [ ]
Home address: _________________________________________
________________________
Street
____________ ________________________
City
Zip
Phone
Parent 1 employer: ________________________________________________________ ___________________
Employer Name (If self employed, please state business name)
Business address: _______________________________________
________________________
Street
Cell
____________ _________________________
City
Parent 2 employer: ________________________________________________________
Zip
Phone
___________________
Employer Name (If self employed, please state business name)
Business address: _______________________________________
______________________
Phone
______________________
Phone
________________________
Street
Cell
____________ _________________________
City
Zip
Phone
Email address: __________________________________________ Person financially responsible for child’s dental care: _______________________________
Emergency contact 1:__________________________ _________________________ __________________ ___________ __________ _______________
Full Name
Street
City
State
Zip
Phone
Emergency contact 2:__________________________ _________________________ __________________ ___________ __________ _______________
Full Name
Street
City
State
Zip
Phone
The permission of parent or guardian is necessary for dental treatment of a minor. I give the dentist permission to use such measures as deemed necessary in his/her professional
judgment to render the best dental treatment for my child. I understand, a late charge of 1.5% per month or a minimum late charge of $10.00 will be added to unpaid balances over 30
days past due and where appropriate, credit bureau reports may be obtained. Unpaid accounts are subject to collection costs.
____________________________________________________
______________________________ __________________
Signature
Relationship
Date
Insurance Information
Do you have dental insurance coverage for this child? Yes [ ] No [ ]
Parent 1 Insurance: ___________________________________________ ___________________
Name of insurance company
Group No.
Address of insurance company: _____________________________ ______________________ ___________ ___________
Street
City
Parent 2 Insurance: ___________________________________________
State
Zip
___________________
Name of insurance company
Group No.
Address of insurance company: _____________________________ ______________________ ___________ ___________
Street
City
State
Zip
I hereby authorize payment to the above named dentist of the group dental benefits, otherwise payable to me but not to exceed the charges shown on the claim. I
understand I am financially responsible for any charges not covered by my insurance by this authorization.
____________________________________________________
______________________________ __________________
Signature
3425 Valle Verde Dr. Napa, CA 94558
Relationship
|
T: (707) 265-8389
|
F: (707) 265-8444
|
frontdesk@drangie.com |
Date
www.napapediatricdentistry.com
Page 2 of 2