Анкета несовершеннолетнего первичного пациента

Name of parent (guardian, legal representative) *

Email *

Contact Number *

Child's name *

Date of birth of the child *

Age (full years) *

Weight of the child at the time of the first appointment *

When was the last time you went to the dentist? *

Main reason for contacting our clinic (please specify in your own words what concerns you about the condition of your child's teeth, smile, face) *

Other

How many pregnancies has the child had? *

If "Yes", please indicate which ones and at what term.

Due date of delivery (what week) *

Breastfeeding (up to what age) *

Night feedings of the child (up to what age) *

Pacifier, finger sucking, bottle sucking (up to what age) *

At what age did teething begin? *

Other

If "Yes", what do you think this is related to:

Other allergen

Please give more details about the child's diagnosis, course and treatment if you have answered any of the points of the previous question (if not, just skip it).

If "Yes", specify which one

What medications has the child been taking?

If 'Yes', please specify which ones, at what time of day, and when was the last intake.

If 'Yes', please specify which one

If 'Yes', then which ones

Is the child currently under the care of a doctor (if yes, which one)?

If "Yes", indicate with what

Age of older siblings, if any