Myers Pediatric Dentistry & Orthodontics Patient Intake

Patient Name

Chart #

Patient Phone Number

Patient Date of Birth

Select Location

Patient Dental History

Please answer the following questions

Does your child brush, floss, or use any other dental aids?

Yes

Is your child taking fluoride of any form?

Yes

Do your child's gums bleed while brushing or flossing?

Yes

Does your child feel pain to any teeth?

Yes

Do you have any areas of concern?

Yes

Has your child had any injuries to his or her mouth, teeth, or head?

Yes

Has your child ever experienced clicking or pain of the jaw?

Yes

Has your child ever experienced difficulty opening, closing, or chewing?

Yes

Does your child breathe through his or her mouth?

Yes

Does your child have frequent headaches?

Yes

Does your child clench or grind his or her teeth?

Yes

Do you assist your child while flossing and brushing?

Yes

Are you pleased with the appearance of your child's smile?

Yes

Has the mother or primary caregiver had cavities in the past 12 months?

Yes

Does your child sleep with a bottle at night?

Yes

Does your child's bottle or sippy cup contain fluid other than milk or water?

Yes

Does your child suck his or her thumb and/or fingers?

Yes

Does your child bite his or her nails?

Yes

Does your child enjoy chewing gum?

Yes

Does your child drink sodas?

Yes

Patient Medical History

Physician

Office Phone

Routine Exams?

Yes

1. Is your child under medical treatment now?

Yes

2. Has your child been hospitalized for any surgical operation or serious illness?

Yes

3. Does your child have or has your child had any of the following?

Fainting/Seizures

Yes

Low Blood Pressure

Yes

High Blood Pressure

Yes

Epilepsy

Yes

Convulsions

Yes

Abnormal Bleeding

Yes

Hemophilia

Yes

Anemia

Yes

Kidney or Liver Disease

Yes

Congenital Heart Defect

Yes

Heart Murmur

Yes

Heart Trouble

Yes

Respiratory Problems

Yes

Thyroid Problem

Yes

Leukemia

Yes

Cancer

Yes

Radiation Therapy

Yes

Tuberculosis

Yes

Hearing Impairment

Yes

Diabetes

Yes

AIDS or HIV

Yes

Jaundice

Yes

Hepatitis

Yes

Stomach Ulcers

Yes

Hay Fever

Yes

Allergies

Yes

Asthma

Yes

ADHD

Yes

Special Needs

Yes

Other

Yes

4. Is your child taking any medications (including non-prescription medicines)?

Yes

5. If yes, what medications is he or she taking?

6. If your child has asthma, when was his or her last episode?

7. Is your child allergic to any of the following: (Please check which ones)

Local anesthetics

Aspirin

Latex

Iodine

Sulfa Drugs

Red Dye

Penicillin or other antibiotics

None

Other

If other, please specify

Authorization, Release, & Agreement to Pay for Services Rendered

• I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me to third party payers and/or health practitioners.
• I authorize and hereby request my Insurance company to pay directly to the dentist (or the dental practice) insurance benefits that otherwise are payable to me.
• I understand that my dental insurance carrier may pay less than the actual bill for services.
• I agree to be responsible for all services rendered on my behalf or on behalf of my dependents.

I certify that I have read and understand the above information. To the best of my knowledge, the above answers have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health.

Patient Name Validation

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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