What to Bring:

What to Expect:

We will treat your child with respect. You may be present in the room for hygiene visits. Our hygienist will introduce your child to getting their teeth cleaned. Fluoride varnish will be applied to all teeth.

We begin recommending digital X-rays when a child reaches 7 years old. If there is a particular concern, an appropriate X-ray can be taken at an earlier age. Cavity-detecting X-rays are taken at age 7 to check between the back teeth. It is important to preserve baby teeth until nature tells us they are ready to be replaced with adult teeth. This occurs at any time from age 5 to 14. A baseline Panorex is recommended at age 8 to be certain all the adult tooth buds are forming correctly.

Your child will leave with a photo of them sitting in the chair and a bag of goodies and a selection from the prize basket. To learn more and set up your child’s next visit with our friendly dentist in Durham, North Carolina, call us today at 919-682-5327! Dr. Ellis K. List is looking forward to meeting your child.

PATIENT DETAILS
Has the patient been examined by an orthodontist before?
GUARDIAN #1 / INSURANCE INFORMATION

INSURANCE (IF APPLICABLE):

GUARDIAN #2 / INSURANCE INFORMATION
Is there a second guardian and / or additional insurance to add?

ORTHODONTIC INSURANCE (IF APPLICABLE):

SLEEP / AIRWAY ISSUES
Does the patient tend to be a mouthbreather?
Does the patient snore at night?
Does the patient seem rested in the morning?
Is the patient often sleepy during the day?
Has the patient seen an Ear, Nose & Throat Specialist?
Is the patient using a sleep apnea device?
DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

Acid Reflux
ADHD/ADD
AIDS/HIV
Anemia
Arthritis
Asthma
Autism
Bone Disorders
Cancer
Cerebral Palsy
Chest Pain
Chronic Neck Pain
Clicking of Jaw
Jaw Pain
Cold Sores/Herpes
Diabetes
Down Syndrome
Endocrine Problems
Emotional Disorders
Epilepsy
Headaches
Heart Condition
Hepatitis
Ear Pain
Immune Problems
Kidney Problems
Low Blood Pressure
Muscular Disorders
Nervous Disorders
Organ Transplant
Osteoporosis
Painful Chewing
Periodontal Problems
Prolonged Bleeding
Rheumatic Fever
Scoliosis
Seizures
Sinus Problems
TMJ Problems
Tuberculosis

Do your gums bleed when you brush?
Is the patient seeing any other dental specialists?
Any dental restorations needing to be completed?
Have there ever been any injuries to the face, mouth or chin?
Have you ever lost or chipped any teeth?
Do you have any pain or soreness around your face, neck or back?
Is any part of your mouth sensitive to temperature or pressure?
Is the patient currently pregnant?
Have adenoids been removed?
Have tonsils been removed?
Currently taking any medications?
Are antibiotics necessary prior to treatment?
Allergies?
Any diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip biting
Clenching Teeth
Fingernail Biting
Grinding Teeth
Tongue Sucking
Thumb Sucking
Tongue Thrusting