<p> Angelina Ring, DDS, Inc. Health History Form</p><p>Patient Information</p><p>______Gender: Male [ ] Female [ ] ____/____/______Child’s First Name Middle Last Birth Date</p><p>Purpose of visit: ______Concerns: ______Last dental visit: ______</p><p>Name and age of brothers and sisters: ______</p><p>Is your child adopted? Yes [ ] No [ ]</p><p>Child’s interests: ______Name of pet: ______</p><p>Does your child have any special needs?______</p><p>Child’s learning: Slow [ ] Average [ ] Accelerated [ ]</p><p>Child’s previous dentist: ______Family Dentist: ______</p><p>Orthodontist:______Who may we thank for referring you to us?______</p><p>Health History Reviewed: ______</p><p>Child’s Pediatrician: ______Date: ______Name Phone Last Physical</p><p>Is your child under a physicians care now? Yes [ ] No [ ] If Yes, Reason: ______</p><p>Pharmacy:______Name Address </p><p>Has your child received all immunizations? Yes [ ] No [ ]</p><p>Is your child taking medications or drugs? Yes [ ] No [ ] If Yes, What kind? ______Reason: ______</p><p>Has your child ever been hospitalized? Yes [ ] No [ ] If Yes, Reason: ______</p><p>Is your child allergic to any medications? Yes [ ] No [ ] If Yes, Please list: ______</p><p>Does your child have an allergic reaction to: [ ] eggs [ ] latex [ ] soy [ ] dust [ ] foods [ ] animals [ ] pollen [ ] other :______</p><p>Does your child have any of these habits: [ ] finger/thumb sucking [ ] pacifier [ ] lip sucking [ ] lip sucking [ ] snoring [ ] teeth grinding</p><p>Has your child had any injuries to teeth, mouth or head? Yes [ ] No [ ] If Yes, Describe: ______</p><p>Has your child had a history or difficulty with any of the following? Yes [ ] No [ ] Premature Birth Yes [ ] No [ ] Earaches Yes [ ] No [ ] Speech Disorder Yes [ ] No [ ]Nosebleeds Yes [ ] No [ ] Heart Yes [ ] No [ ] Kidney Yes [ ] No [ ] Hearing Yes [ ] No [ ] Asthma Yes [ ] No [ ] Seizures Yes [ ] No [ ] Bleeding Yes [ ] No [ ] Brain injury Yes [ ] No [ ] Liver Yes [ ] No [ ] Immune disorder Yes [ ] No [ ] Cerebral Palsy Yes [ ] No [ ] Bruising Yes [ ] No [ ] Brain Yes [ ] No [ ] Allergy to medication Yes [ ] No [ ] Anemia Yes [ ] No [ ] Bladder Yes [ ] No [ ] Rheumatic fever Yes [ ] No [ ] Diabetes Yes [ ] No [ ] Motion sickness Yes [ ] No [ ] Fainting or dizziness Yes [ ] No [ ] Tuberculosis Yes [ ] No [ ] Hepatitis Yes [ ] No [ ] Cancer Yes [ ] No [ ] Delayed Development Yes [ ] No [ ] Autism Yes [ ] No [ ] ADD/ ADHD Yes [ ] No [ ] Emotional or school problems Any medical condition not mentioned above:______</p><p>How may we help make this visit a positive experience for your child? ______</p><p>Notice of Privacy Practices I have received a copy of Napa Pediatric Dentistry’s Notice of Privacy Practices and Dental Materials Fact Sheet. You may refuse to sign this acknowledgement. </p><p>______</p><p>3425 Valle Verde Dr. Napa, CA 94558 | T: (707) 265-8389 | F: (707) 265-8444 | [email protected] | www.napapediatricdentistry.com</p><p>Page 1 of 3</p><p>Angelina Ring, DDS, Inc. Health History Form</p><p>Signature Print Name Relationship to Patient Date </p><p>3425 Valle Verde Dr. Napa, CA 94558 | T: (707) 265-8389 | F: (707) 265-8444 | [email protected] | www.napapediatricdentistry.com</p><p>Page 2 of 3</p><p>Angelina Ring, DDS, Inc. Health History Form</p><p>General Information</p><p>Parent 1 : ______-_____-______/____/______Full Name Social Security Number Phone Cell Birth Date</p><p>Parent 2: ______-_____-______/____/______Full Name Social Security Number Phone Cell Birth Date</p><p>Marital Status: Single [ ] Married [ ] Divorced [ ]</p><p>Child resides with: Both parents [ ] Parent 1 [ ] Parent 2 [ ]</p><p>Home address: ______Street City Zip Phone</p><p>Parent 1 employer: ______Employer Name (If self employed, please state business name) Phone Cell </p><p>Business address: ______Street City Zip Phone</p><p>Parent 2 employer: ______Employer Name (If self employed, please state business name) Phone Cell</p><p>Business address: ______Street City Zip Phone</p><p>Email address: ______Person financially responsible for child’s dental care: ______</p><p>Emergency contact 1:______Full Name Street City State Zip Phone</p><p>Emergency contact 2:______Full Name Street City State Zip Phone</p><p>The permission of parent or guardian is necessary for dental treatment of a minor. I give the dentist permission to use such measures as deemed necessary in his/her professional judgment to render the best dental treatment for my child. I understand, a late charge of 1.5% per month or a minimum late charge of $10.00 will be added to unpaid balances over 30 days past due and where appropriate, credit bureau reports may be obtained. Unpaid accounts are subject to collection costs.</p><p>______Signature Relationship Date</p><p>Insurance Information</p><p>Do you have dental insurance coverage for this child? Yes [ ] No [ ]</p><p>Parent 1 Insurance: ______Name of insurance company Group No.</p><p>Address of insurance company: ______Street City State Zip </p><p>Parent 2 Insurance: ______Name of insurance company Group No.</p><p>Address of insurance company: ______Street City State Zip </p><p>I hereby authorize payment to the above named dentist of the group dental benefits, otherwise payable to me but not to exceed the charges shown on the claim. I understand I am financially responsible for any charges not covered by my insurance by this authorization.</p><p>______Signature Relationship Date </p><p>3425 Valle Verde Dr. Napa, CA 94558 | T: (707) 265-8389 | F: (707) 265-8444 | [email protected] | www.napapediatricdentistry.com</p><p>Page 3 of 3</p>