Tooth Fairy Dental on Eglinton
Orthodontic Intake Form - Child
161 Eglinton Ave E, Unit 1, Toronto, ON M4P 1J5
416-546-9870
Welcome to Tooth Fairy Dental on Eglinton
Personal Information
Patient's Name:
Patient's E-mail:
Patient's D.O.B.
Age:
Gender Identity
Female
Male
Street:
City:
Province:
Postal Code:
Number of children in family:
Ages and names of other children:
Patient's Dentist:
Who may we thank for referring you?
Patient's Physician:
Physician's Tel:
Parent / Guardian's Name:
Phone Number:
Parent Occupation:
E-mail:
Parent / Guardian's Name:
Phone Number:
Parent Occupation:
E-mail:
Parental Relationship:
Yes
Widowed
Separated
Divorced
Single
Common Law
Person Responsible for the Account:
Medical History
Have you been treated for any of the following?
Yes
No
Yes
No
Frequent Colds
Leukemia/Cancer
ADD / ADHD
Tuberculosis
Rheumatic Fever
Endocrine Problems
Autism Spectrum
Asthma
Heart Murmur/Heart Disease
H.I.V. / A.I.D.S.
Emotional Disorder
Tonsillitis
Prolonged Bleeding/Blood Disease
Hepatitis A, B, or C
Artificial Heart Valve
Adenoids
Learning/Behavioral Condition
Diabetes
Eczema
Other
Liver Disease/Jaundice
Epilepsy
Vision Problems
Kidney Disease
Bone Disorders
Mouth-breathing
If you checked off any of the above please give pertinent details:
Is the child being treated for any medical conditions?
Yes
No
Not Sure / Maybe
If yes, please explain:
List any drugs or medications being taken (Please give reason):
Does the child have any history or major illness and/or operations?
Yes
No
Not Sure / Maybe
If yes, please explain:
List any allergies or drug sensitivities:
Have tonsils or adenoids been removed? If so at what age?
Does the child have a tendency to cold sores, sore throats, or ear infections? (Please list):
Dental History
Has the child ever been treated for a jaw joint problem, including surgery?
Yes
No
Have there been any injuries to the face, mouth, teeth?
Yes
No
If yes, please describe:
Has the child ever sucked their thumb or fingers?
Yes
No
If so, until what age?
Does the child have any speech problems?
Yes
No
Does the child get frequent canker or cold sores?
Yes
No
Is the child a mouth-breather?
Yes
No
Have you been informed of any missing or extra permanent teeth?
Yes
No
Is the child especially apprehensive towards dental visits?
Yes
No
Please name any family members treated in our office:
When did the child last see the family dentist?
I hereby give members of the staff permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment plan in progress.
I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.
Signature
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