Child Health History Form

DATE BIRTHDATE AGE
MALE FEMALE

CHILD'S FIRST AND LAST NAME NICKNAME SCHOOL GRADE
HOME PHONE ADDRESS SSN
CITY STATE ZIP
PARENT EMAIL HOBBIES/SPORTS
WHO IS ACCOMPANYING PATIENT TODAY RELATION
OTHER SIBLINGS/AGES DO YOU HAVE LEGAL CUSTODY OF THIS CHILD? YES NO
WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE? OTHER FAMILY MEMBERS SEEN BY US
PRIMARY REASON FOR YOUR VISIT:

I REQUEST APPOINTMENT REMINDERS VIA: EMAIL TEXT BOTH NONE

PARENT'S INFORMATION
PARENT'S MARITAL STATUS: SINGLE MARRIED WIDOWED DIVORCED SEPARATED
PARENT'S NAME BIRTHDATE SSN DRIVER'S LICENSE #
HOME PHONE ADDRESS CELL PHONE
CITY STATE ZIP RELATION
YOUR EMPLOYER BUSINESS ADDRESS OCCUPATION
WORK PHONE CITY STATE ZIP

PARENT'S NAME BIRTHDATE SSN DRIVER'S LICENSE #
HOME PHONE ADDRESS CELL PHONE
CITY STATE ZIP RELATION
YOUR EMPLOYER BUSINESS ADDRESS OCCUPATION
WORK PHONE CITY STATE ZIP
WHO IS THE RESPONSIBLE PARTY FOR THE ACCOUNT


EMERGENCY CONTACT
NAME OF CLOSEST RELATIVE NOT LIVING WITH YOU RELATION
HOME PHONE NUMBER CELL PHONE NUMBER WORK PHONE NUMBER

INSURANCE INFORMATION (PRIMARY)
DO YOU HAVE INSURANCE COVERAGE FOR ORTHODONTIC TREATMENT? YES NO
DO YOU HAVE INSURANCE COVERAGE FOR DENTISTRY? YES NO
EMPLOYEE NAME ID NUMBER BIRTHDATE
INSURANCE COMPANY #1 EMPLOYER GROUP NUMBER

INSURANCE INFORMATION (SECONDARY)
DO YOU HAVE INSURANCE COVERAGE FOR ORTHODONTIC TREATMENT? YES NO
DO YOU HAVE INSURANCE COVERAGE FOR DENTISTRY? YES NO
EMPLOYEE NAME ID NUMBER BIRTHDATE
INSURANCE COMPANY EMPLOYER GROUP NUMBER


HEALTH QUESTIONNAIRE
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

PHYSICIAN NAME DATE OF LAST VISIT


Is the patient taking any medication? YES NO
If YES please specify:

Is the patient allergic to any medication? YES NO
If YES please list:

Does the patient have a history of a major illness? YES NO
If YES please specify:

Has the patient had any major operations? YES NO
If YES please specify:

Have there been any injuries to the face, mouth, teeth or chin? YES NO
If YES please specify:

Has the patient had a history of any of the following?
Asthma Abnormal Bleeding/Hemophilia Epilepsy Hay Fever
Nervous Disorders Herpes Tuberculosis ADD/ADHD
Gastrointestinal Disorders Rheumatic Fever Anemia Sexually Transmitted Disease
Handicap/Disability Radiation/Chemotherapy Sickle Cell Hearing Impairment
Kidney Problems HIV Cancer Heart Murmur
Liver Problems Low Blood Pressure Congenital Heart Defect Hepatitis
Mitral Valve Prolapse High Blood Pressure Stroke Sinus Problems
Ulcers Drug Abuse
OTHER Conditions not listed:
Comments:

Has the patient had any serious illness, operation, or been hospitalized within the past 5 years? YES NO
If so, what was the illness or problem?

Does the patient have allergies to any of the following?
Aspirin Erythromycin Penicillin Codeine
Jewelry/Metals Tetracycline Dental Anesthetics Latex
OTHER allergies not listed:
DENTAL HISTORY
FAMILY DENTIST DATE OF LAST CLEANING
Is the patient presently in any dental pain? Explain: YES NO
If YES please specify:

Has the patient ever experienced any unfavorable reaction to dentistry? YES NO
If YES please specify:

Has the patient ever lost or chipped any teeth? YES NO
Is any part of the patient's mouth sensitive to temperature or pressure? YES NO
Do the patient's gums bleed when you brush? YES NO
Does the patient have any type of thumb or tongue habit? YES NO
Has the patient ever seen an orthodontist? If yes, who and when? YES NO
If YES, who and when?:

Do the patient's teeth or jaw ever feel uncomfortable when they awake in the morning? YES NO
Is the patient aware of their jaw clicking or popping? YES NO
If YES,Explain:

Is the patient aware of clenching their teeth during the day? YES NO
Has the patient ever been told that they grind their teeth? YES NO
Does the patient have tension headaches? YES NO
Has the patient ever experienced chronic ringing in their ears? YES NO
Does the patient have any speech problems? YES NO
How does the patient feel towards ortodontic treatment? ENTHUSIASTIC MOTIVATED NEUTRAL DISINTERESTED

FEMALE PATIENT'S ONLY
Is the patient pregnant? YES NO
Has menstruation started for the patient? YES NO (Relevant to patient's growth status)

Acknowledgment of Privacy Policy

I am aware that a copy of this office's Notice of Privacy Practices is available at request.
I Agree: YES NO

In the subject of minor child, I have listed below the person(s) who may be involved in his/her orthodontic updates and/or transportation.
1. RELATIONSHIP TO PATIENT
2. RELATIONSHIP TO PATIENT
3. RELATIONSHIP TO PATIENT
4. RELATIONSHIP TO PATIENT

AUTHORIZATION

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

SIGNATURE OF PATIENT OR PARENT/LEGAL GUARDIAN DATE


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If printing form, please remember to bring completed form with you to your first visit.


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