Child Patient Form

WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
PATIENT'S NAME
AGE HOME PHONE
CELL PHONE
EMAIL
BIRTH DATE  

NAME
HOME PHONE
CELL PHONE
ADDRESS
EMPLOYER
OCCUPATION
SSN
DOB

NAME
HOME PHONE
CELL PHONE
ADDRESS
EMPLOYER
OCCUPATION
SSN
DOB 

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

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
 
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
 

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?