New Pediatric Patient Information Form

New Pediatric Patient Information

Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Child's Full Name (last, first, middle):

Nickname:

Gender: M F

Date of Birth:

Child's favorite cartoon:

Are they enrolled in school? Y N

School Name:

What grade?

Patient's Home #:

Email address:

SS#:

Patient's Home Address:

How did you hear about our office?

Who is the adult accompanying the patient today?

Do you have legal custody of this child? Y N

Name:

Relationship:

Name (last, first, middle):

Mother Stepmother Guardian

Employer:

Work #:

Ext:

Home #:

Cell:

Email address:

Patient's Home Address:

Name (last, first, middle):

Father Stepfather Guardian

Employer:

Work #:

Ext:

Home #:

Cell:

Email address:

Patient's Home Address:

Insurance Company (IC) Name:

IC Address:

City:

State:

Zip:

IC Phone #:

Group # (Plan, Local, or Policy #):

Policy Holder's Name:

Relationship to Patient:

Policy Holder's DOB:

SS #:

Employer:

Insurance Company (IC) Name:

IC Address:

City:

State:

Zip:

IC Phone #:

Group # (Plan, Local, or Policy #):

Policy Holder's Name:

Relationship to Patient:

Policy Holder's DOB:

SS #:

Employer:

The above information is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form are solely my responsibility. We reserve the right to charge for appointments cancelled or failed without 24 hours advance notice. Weekdays after 4PM and Saturdays will automatically be charged. Payment is due in full at time of treatment unless prior arrangements have been approved. Balances unpaid after 90 days are subject to a late charge of 1.5% per month, and may be reported to the credit bureaus at our discretion. I understand that by signing below I accept financial responsibility for all charges whether or not paid by insurance.

Signature of parent/guardian

Relationship to Patient

Date

Pediatric Medical History

Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Child's Full Name:

Nickname:

Primary Physician:

Gender: M F

Tel:

Cell:

Parent SS#:

Date of Birth:

Height:

Weight:

Date of Last Physical:

Medical Specialists:

Is your child up to date on immunizations against childhood disease? .............................................................. Y N

Is your child taking any medications, vitamins, or dietary supplements? .......................................................... Y N

List name, dose, how often, start date

Has you child ever had a serious injury/surgery or been hospitalized/ER? ....................................................... Y N

List date and describe

Has your child ever had a reaction to or problem with an anesthetic? ............................................................... Y N

Has your child ever had a reaction or allergy to an antibiotic or other medication? ........................................... Y N

Is your child allergic to Latex, foods, dyes, or anything else? .......................................................................... Y N

Please mark Y for "yes" if an item below pertains to your child or mark N for "no" if the item does not apply to your child.

Y N

Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions

Y N

Problems with physical growth or development, weight, or history of eating disorder

Y N

Sinusitis, chronic adenoid/tonsil infections

Y N

Sleep apnea/snoring, mouth breathing, or excessive gagging

Y N

Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease

Y N

Irregular heart beat or high blood pressure

Y N

Asthma, reactive airway disease, wheezing, or breathing problems

Y N

Frequent colds or coughs, or pneumonia

Y N

Frequent exposure to tobacco smoke

Y N

Jaundice, hepatitis, or liver problems

Y N

Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems

Y N

Bladder or kidney problems

Y N

Arthritis, scoliosis, limited use of arms or legs, or muscle/ joint/ bone problems

Y N

Rash/hives, eczema, or skin problems

Y N

Impaired vision, hearing, or speech

Y N

Developmental disorders, learning problems/delays, or intellectual disability

Y N

Cerebral Palsy, brain injury, epilepsy, or seizures

Y N

Autism/autism spectrum disorder

Y N

Recurrent or frequent headaches/migraines, fainting, or dizziness

Y N

Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous)

Y N

Attention deficit/hyperactivity disorder (ADD/ADHD)

Y N

Behavioral, emotional, communication, or psychiatric problems/treatment

Y N

History of known abuse (physical, psychological, emotional, or sexual) or neglect

Y N

Diabetes, hyperglycemia, or hypoglycemia

Y N

Precocious puberty or hormonal problems

Y N

Thyroid or pituitary problems

Y N

Anemia, sickle cell disease/trait, or blood disorder

Y N

Hemophilia, bruising easily, or excessive bleeding

Y N

Transfusions or receiving blood products

Y N

Cancer, tumor, chemotherapy, radiation therapy, or bone marrow or organ transplant

Y N

Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus, methicillin resistant staphylococcus aureaus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS

Provide details for any "Yes" responses above:

Is there any other medical history pertaining to this child or his/her family:

What is your primary concern about your child's oral health?

Your child's oral health is... Excellent Good Fair Poor

Do any of the following apply to your child? For each "yes" please describe

Family history of cavities (who) ................... Y N

Inherited dental characteristics....................... Y N

Mouth sores or fever blisters......................... Y N

Bad breath...................................................... Y N

Cavities/decayed teeth.................................... Y N

Toothache...................................................... Y N

Injury to teeth, mouth, or jaws....................... Y N

Clenching/grinding........................................ Y N

Jaw/Joint problems (popping etc.)................ Y N

Excessive gagging......................................... Y N

Sucking habit after 1 year of age................... Y N

Pacifier Thumb Finger Other

What age did they stop?

How often does your child brush their teeth?

How often does your child have the following?

Does someone help them? Y N

Candy or other sweets

Rarely 1-2/day 3 or more/day

How often does your child floss their teeth?

Products:

Does someone help them? Y N

Chewing Gum

Rarely 1-2/day 3 or more/day

What toothpaste does your child use?

Type:

Snacks between meals

Rarely 1-2/day 3 or more/day

Source of drinking water at home? City/Community Private Well

Usual Snack:

Do you use a water filter? Y N

Type:

Soft Drinks*

Rarely 1-2/day 3 or more/day

Does your child receive any fluoride sources?

(*juice, fruit flavored drinks, sodas, sweetened beverages, sports drinks, or energy drinks)

Over the couter rinse School fluoride program

Pediatrician applied fluoride Prescription fluoride toothpaste

Any other significant dietary habits?

Prescripiton drops/tablets/vitamins

Is your child on a special or restricted diet? Y N

Has your child been examined or treated by another dentist? Y N

Describe:

Date of last visit?:

Were x-rays taken?

Does your child have a diet high in sugars or carbohydrates? Y N

Date of last x-rays?:

Do you have any concerns regarding your child’s weight? Y N

Has your child ever been evaluated by an orthodontist? Y N

Describe:

When?:

Any orthodontic treatment done?

Does your child participate in any sports or similar activities? Y N

Has your child ever had a difficult dental appointment Y N

Does your child wear a mouthguard during these activities? Y N

Describe:

Is there anything else we should know before treating your child?

The information on both pages of this form is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form is solely my responsibility.

Signature of parent/guardian

Relationship to Patient

Date

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Pediatric Dentistry:
Mary-Kathryn Annuzzi, D.M.D.
Annie Creato, D.M.D.

Additional Pediatric New Patient History (Initial Visit Only)

Supplemental History Questions for Infant/Toddler (4 and under);

Was your child born prematurely? Yes No

If YES, What Week?

Weight?

How long was your child breast fed?
N/A less than six months 6-11 months 12-17 months 18-23 months 2 years/more

How long was your child bottle fed?
N/A less than six months 6-11 months 12-17 months 18-23 months 2 years/more

Do/did you feed your child infant formula? Yes No

Does/did your child sleep with a bottle? Yes No

Does/did your child use a no-spill training cup (sippy cup?) Yes No

Child's age (in months) when first tooth appeared in mouth?

Has your child ever experienced any teething problems? Yes No

When did you begin brushing his/her teeth?
N/A less than six months 6-11 months 12-17 months 18-23 months 2 years/more

When did you begin using toothpaste?
N/A less than six months 6-11 months 12-17 months 18-23 months 2 years/more

Who is your child's primary caretaker during the day?

Evening?

Name/age siblings at home

Name of Parent/Guardian

Relationship to child

HIPAA

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

HIPAA OMNIBUS RULE - Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/limited authorization & release form. You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

The undersigned acknowledges having had full opportunity to read and consider the contents of this HIPAA Consent form and the Notice of Privacy Practices. The undersigned understands that, by signing this consent form, they are giving consent to use and disclose their protected health information to carry out treatment, payment activities, insurance and any other office procedures. A copy of this signed and dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS/FACILITIES IN THE FUTURE.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide this information with your knowledge and consent.

Please print patient's name

Patient Signature (if 18 or older)

Parent / Guardian / Legal Representative Signature

Description of Authority

How do you want to be addressed when summoned from the reception area? First Name Only Proper Sir Name Other

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step-parents, grandparents, and/or any caretakers who can have access to this patient's records):

Name:

Relationship:

Name:

Relationship:

I AUTHORIZE Contact from this office to confirm my appointments, treatment, and billing information via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

I AUTHORIZE Contact from this office to information about my health via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

I AUTHORIZE Contact from this office to special services, events, fund raising efforts, or new health info via:

Cell Phone Home Phone Work Phone Text Message My Cell Phone Email Confirmation Any of the Above

Your comments regarding Acknowledgement or Consents

Office Use Only As privacy officer, I attempted to obtain the pateint's (or representative's) signature on this Acknowledgement, but did not because:

It was an emergency treatment

The patient refused to sign

I could not communicate with the patient

The patient was unable to sign because:

Other