Medical Form (for children)

To better understand your dental health needs and your feelings towards orthodontics, please complete this form and submit it prior to your first appointment. Thank you for helping us plan the best care for your child.
 

Patient Information

Child's name:
Last:    First:  MI:
Prefers to be called:

Home address:
Street:   City:
State:   ZIP:  
Home phone:     Male:       Female:     Age:  
Birthdate:

School:   Grade:
Child's dentist:   Physician:
Other family members seen by us:
Whom may we thank for referring you?
Child's interests and activities:
(Sports, hobbies, music, church, activities, or collections)

Parent/Responisible Party - E-mail address:

Father

Name:

Address (if different):
Street:
City:
State:
ZIP:

Mother

Name:

Address (if different):
Street:
City:
State:
ZIP:

 Whom shall we contact if unable to reach mother or father?
Name:      Relationship:
Phone:

Person responsible for account:
Name:     Social Security #
Relationship to patient:     Home phone:
Work phone:     Employed by:

Home address:
Street:     City:
State:     ZIP:

Business address:
Street:     City:
State:     ZIP:

Employee/Subscriber Information (if you have orthodontic insurance)
Employee subscriber name:    SS#
Employed by:    Subscriber date of birth:
Subscriber's relationship to patient:
Ortho insurance company name:
Group #     Insurance company phone #

Dental History & Status
Have you ever had:
 		 Yes  No
    ●  Any injured or broken teeth?   | 
    ●  Any injuries to the head or face?   | 
    ●  Any problems with eating, chewing or swallowing?   | 
    ●  Any dental or facial pain?   | 
    ●  Any jaw joint noise or pain when opening, closing or chewing?   | 
    ●  Any unusual reaction to dental medications?   | 
    ●  A tooth clenching or grinding habit?   | 
    ●  Soreness in the muscles of the face?   | 
    ●  Difficulty breathing with your mouth closed?   | 
    ●  Swellings or growths in the mouth?   | 
    ●  Gums that bleed when brushing your teeth?   | 
    ●  A finger sucking habit?   | 
        If yes, is it still present?  
    ●  Previous orthodontic treatment or consultation?   | 
        When:     Whom:
    ●  What do you think is your child's orthodontic problem?
    ●  What does your child think about his/her teeth and the possibility of braces?
       
    ●  Is there other information we should know?

Medical History
  Yes  No
    ●  Is your child presently in good health?   | 
        Date of last physical exam:
    ●  Is your child being treated by a physician?   | 
        For what?
    ●  Has your child been hospitalized or had a major illness in the last 5 years?   | 
        Please explain:
    ●  Is your child taking any medications or drugs?   | 
        Please list:
    ●  Is your child allergic to any drugs or medicines?   | 
        Please list:
    ●  Are there any congenital problems?   | 
        Please list:
    ●  Have tonsils/adenoids been removed?   | 
    ●  Females: Is there a current pregnancy?   | 
        If yes, give due date:
    ●  Do sores occur in the mouth?   | 
    ●  Has a blood transfusion ever been given?   | 
    ●  Is antibiotic premedication needed before any dental appointments?   | 
    ●  Are there any learning disabilities or extra help needed for instructions?   | 
Have the following ever been diagnosed or treated? Yes  No
    ●  AIDS or HIV Positive?   | 
    ●  ADD (attention deficit disorder)   | 
    ●  Anemia   | 
    ●  Arthritis   | 
    ●  Bone disease   | 
    ●  Cancer or been treated for tumor   | 
    ●  Cerebral palsy   | 
    ●  Diabetes   | 
    ●  Dizziness/fainting spells   | 
    ●  Emotional or behavioral problems   | 
    ●  Epilepsy or neurologic problems   | 
    ●  Glaucoma   | 
    ●  Heart disorders   | 
    ●  Hepatitis or liver problems   | 
        If yes, hepatitis type:
    ●  High or low blood pressure   | 
    ●  Hyperactivity   | 
    ●  Kidney problems   | 
    ●  Substance abuse problems   | 
    ●  Multiple sclerosis   | 
    ●  Immune system problems   | 
    ●  Prolonged bleeding   | 
    ●  Respiratory allergies   | 
    ●  Rheumatic fever   | 
    ●  Scarlet fever   | 
    ●  Shortness of breath   | 
    ●  Sickle cell anemia   | 
    ●  Sinus problems   | 
    ●  Stomach ulcers   | 
    ●  Thyroid or endocrine problem   | 
    ●  Tuberculosis   | 
    ●  Onset of puberty   | 
    ●  Other, please specify:
    ●  Is there any other health information the doctors should be aware of?

Any other comments?

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