Welcome to Sunrise Pediatric Dentistry. The information provided on this form is important to your child's dental health and must be filled out by a parent or legal guardian.  

Please complete this form for new patients ages 3 and under.

*Indicates a required field.

Today's Date *
Today's Date
Patient Information
Patient's Name *
Patient's Name
Gender *
Birthday *
Birthday
How did you hear about our office?
If applicable
Parent or Guardian Information
Parent or Guardian's Name *
Parent or Guardian's Name
Address *
Address
Mobile Phone *
Mobile Phone
Home Phone
Home Phone
Work Phone
Work Phone
Additional Parent or Guardian's Name
Additional Parent or Guardian's Name
Any other decision maker that may accompany your child at future appointments
Address
Address
Mobile Phone
Mobile Phone
Home Phone
Home Phone
Work Phone
Work Phone
Insurance/Financial Information
Name of person responsible for payment; please include phone number and contact information if not listed above
Insurance Company Name (Delta Dental, Cigna etc)
Name of Insured
Name of Insured
Subscriber's Date of Birth
Subscriber's Date of Birth
Insurance Company Name (Delta Dental, Cigna etc)
Name of Insured
Name of Insured
Subscriber's Date of Birth
Subscriber's Date of Birth
Medical History
Date of Most Recent Physical Exam
Date of Most Recent Physical Exam
Is your child being treated by a physician at this time? *
Cardiologist, Endocrinologist or other specialist if applicable
Is your child taking any medication (prescription, over the counter, vitamin or dietary supplement)? *
Has your child ever been hospitalized, had surgery or a significant injury/illness that was treated in the emergency room? *
Has your child ever had a reaction to or problem with an anesthetic? *
Has your child ever had a reaction or allergy to an antibiotic, sedative or any other medication? *
Is your child allergic to latex, or anything else such as metals, dyes, or acrylics? *
Is your child up to date on immunizations against childhood diseases? *
Was your child born prematurely? *
Review of Systems
Any complications before or during birth, prematurity, birth defects, syndromes or inherited conditions? *
Any problems with physical growth or development? *
Sinusitis, chronic adenoid/tonsil infections *
Sleep apnea, snoring, mouth breathing, or excessive gagging *
Difficulty chewing and/or swallowing, or aspiration pneumonia *
Congenital heart defect/disease, heart murmur, rheumatic fever or rheumatic heart disease *
Irregular heart beat or high blood pressure *
Asthma, reactive airway disease, wheezing or breathing problems? *
Cystic fibrosis *
Pneumonia or other serious infections *
Frequent exposure to tobacco smoke *
Jaundice, hepatitis, or liver problems *
Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems *
Prolonged diarrhea, unintentional weight loss, concern with weight, or eating disorder *
Celiac disease, gluten allergy *
Lactose intolerance, food allergies, nutritional deficiency, or dietary restrictions *
Bladder or kidney problems *
Arthritis, scoliosis, limited use of arm and/or legs, muscle, joint or bone problems *
Rash/hives, eczema or other skin problems *
Impaired vision, hearing or speech *
Developmental disorder, learning problems/delays, or intellectual disability *
Cerebral palsy, brain injury, epilepsy, or convulsions/seizures *
Autism/autism spectrum disorder *
Recurrent headaches/migraines, fainting or dizziness *
Hydrocephaly or placement of a brain shunt *
Behavioral, emotional, communication or psychiatric problems/treatment *
Attention deficit/hyperactivity disorder (ADD/ADHD) *
Concerns or history of abuse or neglect *
Diabetes, hyperglycemia, or hypoglycemia *
Precocious puberty or hormonal problems *
Thyroid or pituitary problems *
Anemia, sickle cell disease/trait, or other blood disorder *
Hemophilia, excessive bleeding, or easy bruising *
Transfusions or receiving blood products *
Infectious diseases (mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), MRSA, sexually transmitted disease (STD), or HIV/AIDS *
Cancer, tumors, other malignancies, chemotherapy, radiation therapy, or bone marrow/organ transplant *
History or family history of malignant hyperthermia, or adverse reactions to sedation and/or anesthesia *
Is there any other significant medical history pertaining to this child or his/her family that the dentist should be told? *
Dental History
Reason for your visit
How would you describe your child's oral health? *
How would you describe your oral health? *
Is their a family history of cavities? *
If yes, check all that apply:
Does your child have a history of any of the following?
Mouth sores/fever blisters *
Bad Breath *
Bleeding gums *
Cavities/Decayed Teeth *
Injury to teeth, mouth and/or jaws *
Clenching/grinding
Excessive gagging *
Jaw joint problems (clicking, popping or locking) *
Does your child have any oral habits? *
If yes, indicate all that apply:
Age of child
Does someone help your child brush? *
What kind of toothpaste does your child use? Check all that apply. *
What is the primary source of your drinking water at home? *
How long was your child breast-fed? *
How long was your child bottle fed? *
Does/did your child sleep with a bottle? *
Does your child use a no spill training cup (sippy cup)? *
Is your child on a special or restrictive diet? *
Does your child have a diet high in sugar or starches? *
How frequently does your child have the following?
Candy or other sweets *
Snacks between meals *
Soft drinks, sodas, juices or tea *
Has your child ever had a difficult dental appointment? *
Is there anything else we should know before treating your child? *
To be completed at the office
Thank you for completing our new patient intake form ages 3 and under.