01. Tell Us About Your Child
Child's Full Name
Child's Nickname
Child's DOB
Child's Gender
Child's Home Address
Street Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Home Phone?
Yes
No
Home Phone Number
If no home phone, add cell phone number
Cell Phone Provider
General Dentist
Last Visit Date
Whom may we thank for referring you?
What are your main concerns for this appointment?
02. Parent 1 Information
Marital Status
Full Name
Email
Birthdate
SSN#
Address (If different from child)
Are you the Insurance Subscriber?
Yes
No
03. Parent 2 Information
Marital Status
Full Name
Email
Birthdate
SSN#
Address (If different from child)
Are you the Insurance Subscriber?
Yes
No
04. Dental / Orthodontic Insurance
Do You Have Orthodontic Coverage?
Yes
No
Insurance Co. Name
Subscriber Name
Subscriber ID# or SSN
Is there secondary insurance?
Yes
No
Secondary Insurance
Secondary Insurance Subscriber Name
Secondary Insurance Subscriber ID# or SSN
05. What are the main concerns that you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?
Yes
No
Please Choose One
Have there been any injuries to the face, mouth, teeth or chin?
Yes
No
Please Choose One
List any musical instruments played
Have adenoids or tonsils been removed?
Yes
No
Please Choose One
Has your child been informed of any missing or extra permanent teeth?
Yes
No
Please Choose One
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Yes
No
Please Choose One
Does your child brush his/her teeth daily?
Yes
No
Please Choose One
Floss his/her teeth daily?
Yes
No
Please Choose One
Was your child breastfed?
Yes
No
Not Sure
Please Choose One
Child's Physician
Child's Physician Phone
Is your child currently under the care of a physician?
Yes
No
Please Choose One
Has puberty begun?
Yes
No
Please Choose One
Has menstruation begun? (Girls)
Yes
No
Please Choose One
Please describe your child's current physical health
Good
Fair
Poor
Please Choose One
Please list all drugs that your child is currently taking
Are you taking any prescription or over-the-counter drugs
Please Choose One
Yes
No
If yes, please list:
06. Has your child ever had any of the following medical problems?
Abnormal Bleeding
Yes
No
Please Choose One
Allergies to Any Drugs
Yes
No
Please Choose One
If yes, please list all drugs that your child is allergic to
Allergies to Latex/Metals
Yes
No
Please Choose One
Allergies to Plastic
Yes
No
Please Choose One
Any Hospital Stays?
Yes
No
Please Choose One
Any Operations?
Yes
No
Please Choose One
Asthma
Yes
No
Please Choose One
Bruxism/Grinding
Yes
No
Please Choose One
Cancer
Yes
No
Please Choose One
Clenching
Yes
No
Please Choose One
Congenital Heart Defect
Yes
No
Please Choose One
Convulsions/Epilepsy
Yes
No
Please Choose One
Head and Neck Pain
Yes
No
Please Choose One
Headaches
Yes
No
Please Choose One
Hearing Impairment
Yes
No
Please Choose One
Heart Murmur
Yes
No
Please Choose One
Hemophilia
Yes
No
Please Choose One
Hepatitis
Yes
No
Please Choose One
HIV+/ AIDS
Yes
No
Please Choose One
Keloids
Yes
No
Please Choose One
Kidney/Liver Problems
Yes
No
Please Choose One
Rheumatic/Scarlet Fever
Yes
No
Please Choose One
Sleep Apnea
Yes
No
Please Choose One
Snoring
Yes
No
Please Choose One
ADD
Yes
No
Please Choose One
ADHD
Please Choose One
Yes
No
Aspergers
Please Choose One
Yes
No
Please discuss any medical problems that your child has had
07. Does/did your child have any of the following habits?
Clenching/Grinding Teeth
Yes
No
Please Choose One
Lip Sucking/Biting
Yes
No
Please Choose One
Mouth Breather
Yes
No
Please Choose One
Nail Biting
Yes
No
Please Choose One
Nursing Bottle Habits
Yes
No
Please Choose One
Speech Problems
Yes
No
Please Choose One
Thumb/Finger Sucking
Yes
No
Please Choose One
Tongue Thrust
Yes
No
Please Choose One
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.
I authorize the dental staff to perform the necessary dental services my child may need.
Signature of Parent or Guardian
Patient Signature
Today's Date: