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Minor - New Patient Registration

For Children-

*Patient Name:

Last name

Mid name

First name

Preferred Name:

Date of Birth:

*Address:

				City
Prov.		Postal		APT#

*Home phone #:	()- -	Cell #:	()- -
Work phone #:	()- - -

*Email Address:

Employer:

Occupation :

How did you hear about our office?

Emergency Contact Details -

His/Her Name:

Relationship:

Phone #:

()- -

Cell #:

()- -

Insurance Information

Insurance Primary-

Subscribers Name:

Date of Birth:

Relationship :

Ins. Company:

Group Number #:

ID Number #:

Insurance Secondary-

Subscribers Name:

Date of Birth:

Relationship :

Ins. Company:

Group Number #:

ID Number #:

Assignment and Release


*	I, the undersigned certify that I (or my dependent) have insurance coverage and assign directly to Aberdeen Dental all insurance benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.


*	Consent: I consent to the diagnostic procedures and treatment by the dentist/dental hygienist necessary for proper dental care.

Minor Medical History

Physicians Name:

Please answer Yes or No to the following questions.

Have you been under the care of a physician recently?

Yes No

Name of Family Physician:

2.	Have you ever had a serious illness?	Yes No
3.	Have you ever had any type of allergy, hay fever, or asthma?	Yes No
4.	Have you ever had any allergic reactions?	Yes No

Please list them below (latex, metal, medication etc.)

Are you taking any prescription or non-prescription medications?

Yes No

Please list them:

If you have ever been advised against taking any type of medication:

Yes No

Please list them:

If medical conditions or illness the child has recently had.

Yes No

Please list them:

Please go over the following medical conditions and indicate any that apply to your medical health:

AIDS/HIV

Anemia

Bruise Easily

Artificial joint

Chest Pains

Epilepsy

Heart Attack

Heart Surgery

High BP

Lung Disease

Organ Transplant

Alzheimers

Arthitis/Gout

Asthma

Cancer

Diabetes

Fainting

Heat Murmur

Hemophilia

Kidney Problems

Metal Disorder

Seizures

Anaphlaxis

Artificial Heart Valve

Blood Disease

Chemotherapy

Emphysema

Glaucoma

Heart Pacemaker

Hep A,B, or C

Liver Disease

Nervous Disorder

Sickle Cell Disease

Stroke

Tuberculosis

If Other, Please Mention:

Minor Dental History

How may we help you today?

Are you currently in pain with any of your teeth?

Previous Dentists name:

Location:

Last Dental Visit:

When was your last dental hygiene appointment?


*	I certify that this medical and dental questionnaire is accurate and complete.

Screening Questionnaire

Person Completing Form:

Are you aware of your child-

Snoring/noisy breathing while sleeping	Yes No
Grinding his or her teeth	Yes No
Wetting the bed	Yes No
Having difficulty in school/learning	Yes No
Being treated for ADD or ADHD	Yes No
Breathing primarily through their mouth	Yes No
Having frequent nightmares/night terrors	Yes No
Having frequent ear aches	Yes No

Obstructive Sleep Apnea-

Please answer the following questions as they pertain to your child in the past month.

1.	While Sleeping, does your child:
	Snore more than half the time?	Yes No DK
	Always snore?	Yes No DK
	Snore loudly?	Yes No DK
	Have "heavy" or loud breathing?	Yes No DK
	Have trouble breathing, or struggle to breathe?	Yes No DK
2.	Have you ever seen your child stop breathing during the night?	Yes No DK
3.	Does your child:
	Tend to breathe through the mouth during the day?	Yes No DK
	Have a dry mouth on waking up in the morning?	Yes No DK
	Occasionally wet the bed?	Yes No DK
4.	Does your child:
	Wake up feeling unrefreshed in the morning?	Yes No DK
	Have a problem with sleepiness during the day?	Yes No DK
5.	Has a teacher or other supervisor commented that your child appears sleepy during the day?	Yes No DK
6.	Is it hard to wake your child up in the morning?	Yes No DK
7.	Does your child wake up with headaches in the morning?	Yes No DK
8.	Did your child stop growing at a normal rate at any time since birth?	Yes No DK
9.	Is your child overweight?	Yes No DK
10.	This child often:
	Does not seem to listen when spoken to directly?	Yes No DK
	Has difficulty organizing tasks and activities?	Yes No DK
	Is easily distracted by extraneous stimuli?	Yes No DK
	Fidgets with hands or feet or squirms in seat?	Yes No DK
	Does not seem to listen when spoken to directly?	Yes No DK
	Is "on to go" or often acts as if "driven by a motor"?	Yes No DK
	Interrupts intrudes on others(eg., butts into conversations or games)?	Yes No DK
	TOTAL:

Scoring -

YES = 1

NO = 0

Average all scores to obtain a score between 0.00 to 1.00. Preliminary analyses suggest a cut-off of>0.33 for abnormal.

(For more information see Chervin RD, Hedger K, Dillon JE, Pituch KJ (2000). Pediatric Sleep Questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine 1:21-32)