Carol K. Yeung DDS

500 S. Anaheim Hills Road, Suite 116,

Anaheim Hills, CA 92807, USA

714-978-4664, 714-279-1179

Patient Information

Patient Name:
Date of Birth:
Phone:
Email:
PATIENT’S PEDIATRICAN:
PATIENT’S SCHOOL:
PEDIATRICAN ADDRESS:
City:
Zip Code:
PEDIATRICAN PHONE #:
LAST MEDICAL EXAM:
PREVIOUS DENTIST:
LAST DENTAL EXAM:
PATIENT’S ORTHODONTIST:
LAST ORTHODONTIC EXAM:
List any medication(s) and dosage your child is taking:

MEDICAL HISTORY: (Please select)

1. Is there a history of any illness / disease such as:
Diabetes, Hepatitis, Chicken pox, Herpes, Cancer, Tumors, Asthma, Tuberculosis, STD or Sexually transmitted diseases, HIV, Other?
If Yes, Explain:
2. Any history of the following:
Hospitalizations, Surgeries, Premature birth, birth complications, Indwelling catheters, Shunts, Gastric tubes, Seizures
If Yes, Explain:
3. Does your child have any of the following disabilities?
Emotional, Neurological, Speech, Learning
If Yes, Explain:
4. Does your child take any medication on a regular schedule?
If Yes, Explain:
5. Have any of the following ever been defective in any way:
Eyes, Ears, Heart, Lungs, Kidneys, Liver, Bladder, Intestine, Spleen, Bones
If Yes, Explain:
6. Has your child ever had a bad reaction to any drug, medicine, or anesthetic either in a “shot” or by mouth?
If Yes, Explain:
7. Does your child bleed excessively after cuts or extractions or have any bleeding disorder?
If Yes, Explain:
8. Has your child had any tonsils and/or adenoids been removed or have a history of snoring or sleep apnea?
If Yes, Explain:
9. Has your child had rheumatic fever or infective endocarditic (Heart condition)?
If Yes, Explain:
10. Is your child allergic to anything?
Foods, Medications, Latex
If Yes, Explain:

DENTAL HISTORY: (Please select)

A. Any unfavorable reaction to dental treatment?
If Yes, Explain:
B. Any habits such as the following and to what age?:
Thumbsucking, Finger-sucking, Pacifier, Other sucking/chewing habits, Grinding, Nail biting
If Yes, Explain:
C. Does child have full charge of his/her own tooth brushing?
If Yes, Explain:
D. Does your child eat “sweets” frequently? How many times a day are sugars or carbohydrates eaten?
Fruit juices, crackers, sports drinks, candy
If Yes, Explain:
E. Is there a history of any severe blow to the teeth, face or head?
If Yes, Explain:
F. Has your child taken fluoride vitamins or drops in the past?
If Yes, Explain:
G. Does your child currently take a fluoride supplement?
If Yes, Explain:
H. Do you drink tap water (if so, is it filtered, please specify)
If Yes, Explain:
I. Do you drink bottled water (if so, does it have fluoride)
If Yes, Explain:

To the best of my knowledge the information I have given on this form is correct, and I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status.

FAMILY RECORD AND FINANCIAL RESPONSIBILITY

WELCOME! How did you choose our office?
Reason for this appointment

FAMILY RECORD

Name(s) and age(s) of children to be seen on your initial visit:
Have any family members been patients in our office in the past?
If so, please list:
Patient(s) main residences address:
City:
State:
Zip Code:
Father’s full name:
Marital Status:
Address (if different):
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Occupation:
Employer:
Work Phone:
Work address:
Driver’s License #:
Mother’s full name:
Marital Status:
Address (if different):
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Occupation:
Employer:
Work Phone:
Work address:
Driver’s License #:
Emergency Contact Name:
Relationship:
Phone:
If family is NOT living together, person(s) financially responsible for account:

DENTAL INSURANCE INFORMATION

First Policy

Name of insured:
Relation to child:
Social Security #:
Birth Date:
Group / Policy#:
Ins. Co.:
Employer:
Employee ID#:

Second Policy

Name of insured:
Relation to child:
Social Security #:
Birth Date:
Group / Policy#:
Ins. Co.:
Employer:
Employee ID#:

INFORMED CONSENT

I authorize my insurance company to pay Anaheim Hills Pediatric Dentistry all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance and that all payments are due when services are rendered. I also understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of Anaheim Hills Pediatric Dentistry. This consent is to remain in effect until canceled in writing.

Anaheim Hills Pediatric Dentistry

Patient Name:
Birth Date:
Pediatrician:
Does your child have a current Pediatrician or Primary Doctor?
If so, please provide Name, Address, Phone number below:
Does your child have any physical or learning disabilities or attending any theraphy? If so, please list
Was your child born premature?
If yes
Is your child currently being seen by a physician on a regular basis? (Ex: monthly, weekly, etc)
If Yes
Has your child ever had a head or neck injury? (Ex: Hit to the face, head, or teeth)
If Yes
Does your child snore or have obstructive sleep apnea?
If Yes
Has your child ever been hospitalized or had any operations?
If Yes
Has your child ever been diagnosed with an Innocent Heart Murmur, or any other cardiac conditions?
If Yes, did the cardiac condition require surgery?
If Yes, do you know if your child requires an antibiotic prior to dental cleanings / restorations?
Does your child take any medication(s) regularly?
If so, please list all medication(s) and dosage your child is taking below.
Is your child allergic to any of the following? List any others that are not listed below (especially fruits and foods)
Latex
Codeine
Eggs
Local Anestetics
Metal
Soy
Sulfa Drugs
Dairy
Milk Protein
Penicillin / Amoxicillin / Augmentin
Nuts
Lactose Intolerant
Does your child take any oral contraceptives?
If Yes
Has or is your child pregnant?
Does or has your child taken any recreational drugs?
Does your child have any oral jewelry, such as tongue or lip piercings?
Does your child have, or had, any of the following?
ADHD
AIDS/ HIV Positive
Anaphylaxis
Anemia
Angina
Artificial Heart Valve
Artificial Joint
Asperger’s Syndrome
Asthma
Autism
Blood Disease
Bruise Easily
Cancer
Cerebral Palsy
Chemotherapy
Chicken Pox
Cold Sores / Fever Blisters
Convulsions
Croup
Depression
Diabetes
Down Syndrome
Emphysema
Epilepsy or Seizures
Frequent Headaches
Hand, Food, Mouth Disease
Hay Fever
Heart Murmur
Heart Pacemaker
Hives or Rash
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
Hypoglycemia
Irregular Hearbeat
Kawasaki Disease
Kidney Problems
Leukemia
Liver Disease
Lung Disease
Mitral Valve Prolapse
MRSA
Osteoporosis
Psychiatric Care
Parathyroid Disease
Radiation Treatments
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Splenectomy
Stomach / Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Whooping Cough
Yellow Jaundice

Habits

Does your child have any of the following habits?
Thumb sucking
Finger / Blanket sucking
Pacifier
Grinding
Nail Biting

I have read all the questions and answered them to my knowledge that everything is correct.

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Guardian's Signature:

Use your mouse cursor or the tip of your finger to sign below

Name:
Date:

Doctor's Signature:

Use your mouse cursor or the tip of your finger to sign below

Name:
Date: