Child Patient Form
MINOR PATIENT INFORMATION
WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
PATIENT'S NAME
AGE
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE
CELL PHONE
EMAIL
BIRTH DATE
Are any immediate family members treated here?
Yes
No
If yes, please list names
SEX
PARENT 1 INFORMATION
NAME
HOME PHONE
CELL PHONE
ADDRESS
EMPLOYER
OCCUPATION
SSN
DOB
PARENT 2 INFORMATION
NAME
HOME PHONE
CELL PHONE
ADDRESS
EMPLOYER
OCCUPATION
SSN
DOB
DENTAL INSURANCE INFORMATION
INSURED'S NAME
DENTAL INSURANCE COMPANY
GROUP NUMBER
INSURED'S ID
INSURED'S SSN
DENTAL INSURANCE COMPANY ADDRESS
PHONE NUMBER
IS POLICY CONNECTED WITH YOUR UNION?
YES
NO
Does the patient have DUAL COVERAGE? If yes, please complete the following secondary insurance info:
YES
NO
INSURED'S NAME
DENTAL INSURANCE COMPANY
GROUP NUMBER
INSURED'S ID
INSURED'S SSN
DENTAL INSURANCE COMPANY ADDRESS
PHONE NUMBER
IS POLICY CONNECTED WITH YOUR UNION?
YES
NO
GENERAL INFORMATION
MARITAL STATUS OF PARENTS
MARRIED
DIVORCED
SINGLE
NUMBER OF CHILDREN IN THE FAMILY
NAME OF ANY FAMILY MEMBER IN TREATMENT OR PREVIOUSLY WITH US
NAME OF PREVIOUS ORTHODONTIST
GENERAL DENTIST'S NAME
GENERAL DENTIST'S ADDRESS
GENERAL DENTIST'S PHONE
DATE OF LAST DENTAL CHECK-UP
CURRENTLY UNDER TREATMENT?
YES
NO
PHYSICIAN'S NAME
ADDRESS
PHONE
DATE OF LAST CHECK-UP
CURRENTLY UNDER TREATMENT?
YES
NO
ANY HISTORY OF
:
Thumb or finger sucking
Grinding of teeth
Frequent headaches or jaw pain
Difficulty eating any foods
Speech difficulty or speech therapy
What are the patient's hobbies?
In your own words describe the patient's main orthodontic problem?
MEDICAL HISTORY
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.
Is the patient in general good health at this time?
YES
NO
Is the patient under any medical treatment now?
YES
NO
Is the patient taking any drugs or medications?
YES
NO
If yes, please list medications:
Has the patient ever had any adverse response to any drugs, including penicillin?
YES
NO
Is the patient allergic to any known materials resulting in hives, asthma, eczema, etc.?
YES
NO
Is the patient allergic to latex?
YES
NO
Has the patient ever had any major operations including hip/joint replacement?
YES
NO
Does the patient have any wounds that healed slowly or presented other complications?
YES
NO
Has the patient had any radiation therapy or chemotherapy?
YES
NO
Has the patient had a serious accident involving head injuries?
YES
NO
Has the patient had a history of any of the following?
ASTHMA
HEART MURMUR
TUMOR OR GROWTH
TONSILLITIS
AIDS OR HIV POSITIVE
FAINTING
DIABETES
MIGRAINE HEADACHES
CARDIOVASCULAR DISEASE
HERPES
RESPIRATORY PROBLEMS
BONE DISORDER
EXCESSIVE BLEEDING
EPILEPSY
ARTHRITIS OR PAINFUL JOINTS
DRUG ABUSE
CANCER
SINUS PROBLEMS
BLOOD DISEASE
EMOTIONAL PROBLEMS
CONVULSIONS
INFECTIOUS DISEASE
ALCOHOLISM
HAY FEVER
RHEUMATIC FEVER
SEXUALLY TRANSMITTED DISEASE
DIZZINESS
IMMUNE SYSTEM PROBLEMS
HEPATITIS OR LIVER DISEASE
HEARING DISORDER
OTHER Conditions not listed:
Does the patient snore?
YES
NO
Does the patient have unexplained awakenings from sleep?
YES
NO
Does the patient stop breathing for short periods during sleep?
YES
NO
Does the patient get excessively tired during the day and/or fall asleep when they should be awake?
YES
NO
Is the patient on a diet at this time?
YES
NO
Does the patient have a history of fainting?
YES
NO
Is the patient pregnant?
YES
NO
Has the patient ever smoked or used Tobacco products?
YES
NO
Is there any history of biphosphanate or calcium medication for bone?
YES
NO
If so, what is the name of the medication?
FEMALES: Started Menstruation?
YES
NO
If so, how long ago?
DENTAL HISTORY
The following information is requested to enable us to give the patient the best consideration of their 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.
When were the patient's last full-mouth x-rays taken?
Where?
Do the patient's gums bleed?
YES
NO
Has the patient ever had gum disease, or periodontal treatment?
YES
NO
Does the patient frequently get sore spots in their mouth?
YES
NO
Does the patient have any dental complaints at the present time?
YES
NO
Does the patient experience frequent headaches?
YES
NO
Does the patient have a history of back or neck injuries? Whiplash?
YES
NO
Does the patient have any clicking or popping of their jaw (TMJ)?
YES
NO
Does the patient have pain in or around their ears?
YES
NO
Does any part of the patient's mouth hurt when clenched?
YES
NO
Does the patient habitually clench or grind their teeth during the night or day?
YES
NO
Does the patient chew on only one side of their mouth?
YES
NO
If so, why?
Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc )?
YES
NO
If so, where?
Has the patient ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?
YES
NO
Has the patient ever taken medication for treatment of Osteoporosis?
YES
NO
In case of emergency, contact:
Phone:
PURPOSE OF CONSENT (HIPAA)
By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.
SIGNATURE OF PARENT/GUARDIAN:
DATE:
If you would like a copy for your personal records, please request one in our office.