Patient Intake Form - Child - Tooth Fairy Dental on Eglinton

Welcome to Tooth Fairy Dental on Eglinton

In order to provide you with optimum dental care we require a thorough medical and dental history which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer all questions on this questionnaire.

Patient's Name:

Patient's E-mail:

Patient's D.O.B.

Gender Identity
Female Male

Street:

City:

Province:

Postal Code:

Name:

Address (if different):

Tel. Home:

Tel. Cell:

Tel. Work:

Occupation:

E-mail:

Name:

Address (if different):

Tel. Home:

Tel. Cell:

Tel. Work:

Occupation:

E-mail:

Person Responsible for the Account:

Purpose of visit:

Referred by:

How did you hear about us? (Check all that apply)

Patient Referral:

Flyer

Google Search

Social Media

Signage

Other — please specify:

Emotional/behavioral disorders:
Yes No

If yes, please specify:

Allergies (Food, Medication):
Yes No

If yes, please specify:

Other:
Yes No

If yes, please specify:

Physician’s Name:

Office Number:

Does your child visit the Physician regularly:
Yes No

Date of last visit:

Is your child taking any medication now?
Yes No

Date of last visit:

Has your child taken fluoride drops/tablets:
Yes No

If yes, when did he/she begin?

Is your child currently taking fluoride supplements?
Yes No

Amount?

Physician’s Name:

Office Number:

Does your child visit the Physician regularly:
Yes No

Date of last visit:

Is your child taking any medication now?
Yes No

Date of last visit:

Has your child ever lived in a fluoridated area?
Yes No Unsure

If yes, where?

Who brushes their teeth?
Parent Child

Are your child’s teeth flossed:
Yes No

If yes, how often:

Which of the following applies to your child?

Who prepares the food:

During infancy did your child have a pacifier?
Yes No

Until what age?

During infancy did your child take a bottle in the crib?
Yes No

If yes, what did the bottle contain?

Has your child had any of the following habits?

Fingersucking Yes No

Thumbsucking Yes No

Until what age?

How does your child respond at the Physician?

Has your child been hospitalized?
Yes No

If yes, where?

When?

How did your child respond at the hospital?

Has your child been to the dentist?
Yes No

Name of previous dentist:

When was last dental visit?

Reason for visit?

How did your child respond?

How did you think your child will respond today?

To the best of my knowledge, the above information is correct.

	Yes	No		Yes	No
Scarlet Fever			HIV Positive
Autism/ASD			Vision Problems
Blood Transfusion			Rheumatic Fever
Asthma			Liver Disease
Hearing Problems			Meningitis
Heart Murmur			Lung Disease
Blood Disorders			Learning Disability
Celiac			Heart Disease
Tuberculosis			Bleeding Problems
Bone Disorder			Diabetes
Convulsions			Kidney Disease
Skin Disease			Snoring
Hepatitis			Cancer
Premature Birth			Eczema
Mouth Breathing

	Yes	No		Yes	No
Peanut butter			Cakes, pies, cookies
Fruit juice			Koolaid
Candy			Canned fruit
Raisins			Sugared cereals
Soft drinks/pop			Gum
Ice cream			Jams/jellies
Sweetened vitamins

	Yes	No		Yes	No
X-rays			Local anesthetic (freezing)
Extractions			Orthodontics
Fluoride treatment			Restorative dentistry (fillings)
General anesthesia

Patient 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

Parent / Guardian

Parent / Guardian

Medical History (Confidential)

Prevention History

Behaviour History

Signature

	Yes	No		Yes	No
Snacks often			Good eater at meals
Eats or drinks before bedtime			Needs a drink during the night -

	Yes	No		Yes	No
Breakfast			Lunch
Dinner			Bedtime