Although dentistry deals with primarily teeth and its surrounding structures, oral cavity is a part of the entire body. Health problems that your child may have, or medications that your child may be taking could have an important interation with dentistry your child may receive. Thank you for answering the following questions thoroughly.
The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.
Patient First Name: *
Patient Middle Name:
Patient Last Name: *
Date of birth: *
-month-JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember -day-12345678910111213141516171819202122232425262728293031 -year-19181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018
Patient Gender: *
Name of Child's Physician?:
Child Physician's Phone Number:
Any problems/complications durning pregnancy/delivery? If yes, please explain: *
Does your child have any health problems? If yes, please explain: *
Has your child been diagnosed with any medical conditions? If yes, please explain: *
Has your child ever been hospitalized? If yes, please explain (For & When): *
Has you child ever had surgery? If yes, please explain (For & When): *
Is your child taking any medication? If yes, please list: *
Is your child allergic to any medications/food/latex? If yes, please list: *
Are your child's immunizations up to date?: *
Check any of the following for which the patient has been treated:
Main reason for today's visit?:
How often are the child's teeth brushed?
How often are the child's teeth being flossed?
Who does the brushing and flossing?
When was your child weaned off nursing/bottle?
Does your child have any oral habits?
History of Dental Trauma? If yes, please explain:
How would you rate mother's oral health?
How would you rate father's oral health?
How would you rate your child's candy consumption? (candy, juice, etc)
Is there any additional medical/dental information you may want the dentists at Hi5 Dental to know?
It may take a moment to submit your information. Please wait for a confirmation message.
| Meet The Doctors
| Dentistry for Kids
| Office Info
| New Patients
| Referring Doctors
| Hai Pham, DMD
| Jenette Intrachat, DDS
| Frank Hsieh, DDS, MSD
| Dental FAQ
| First Visit
| Preventive Care
| Treating Decay
| Early Orthodontics
| Sports & Mouthguards
| Special Needs
| Sedation Dentistry
| Dental Emergencies
| Hi5 Dental in Hillsboro
| Hi5 Dental in Cedar Hills