Patient Form (Child)

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Date
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthdate
School
Sports/Hobbies
Parent/Guardian name
Whom may we thank for referring you to our office?
Responsible Party Information
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long at this address?
Phone
Email
Previous Address (if less than 3 years)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthdate
Relationship to the patient
Employer
Occupation
No. years employed
Spouse's name
Relationship to Patient
Employer
Occupation
No. years employed
Birthdate
Work/Personal Phone
Dental Insurance Information
Insured's Name
Insurance Company
Group No.
Local No.
Insurance Co. Address
Phone
Do you have dual coverage? Yes, No?
If Yes
Insured's Name
First
Insurance Company
Group No.
Local No.
Insurance Co. Address
Phone No.
Emergency Information
Name of nearest relative not living with you:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
I understand that, where appropriate, credit bureau reports may be contained
Name/Signature
Date
Medical History
Physician
Date of last visit
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Is the patient taking any medication? Yes or no?
If yes, please specify what medication
Is the patient allergic to any medication?
If yes, please specify what medication
History of a major illness?
If yes, please specify what illness
Has the patient had any operations?
If yes, please specify
Ever been involved in a serious accident?
If yes, please specify
Have seen a physician in the last 12 months? Why?
For female patients only: Has menstruation started?
For female patients only: Is the patient pregnant?
Check any of the medical conditions below that the patient has had or currently has
- Abnormal bleeding/hemophilia
- Anemia
- Arthritis
- Asthma or Hayfever
- Bone disorders
- Congenital Heart Defect
- Diabetes
- Dizziness
- Epilepsy
- Gastrointestinal Disorders
- Heart Problems
- Heart Murmur
- Hepatitis/Liver Problems
- Herpes
- High Blood Pressure
- HIV/AIDS
- Kidney Problems
- Nervous Disorders
- Pneumonia
- Prolonged Bleeding
- Radiation/Chemotherapy
- Rheumatic Fever
- Tuberculosis
- Tumor or Cancer
Dental History
General Dentist
First Last
Date of last visit
What concerns you most about your teeth?
Is the patient presently in any dental pain?
Ever experience any unfavorable reaction to dentistry?
Has the patient ever lost or chipped any teeth?
Have there been any injuries to face, mouth, or teeth?
Is any part of your mouth sensitive to temperature? Where?
Is any part of your mouth sensitive to pressure? Where?
Do your gums bleed when brushing?
Any type of thumb or tongue habit?
Is the patient a mouth breather?
Has the patient ever seen an orthodontist? If yes, who and when?
What is the patients attitude toward receiving orthodontic treatment?
Has anyone in the family received orthodontic treatment?
How did they feel about the result?
Do teeth or jaws ever feel uncomfortable first thing in the morning?
Experience jaw clicking or popping?
Aware of clenching or grinding teeth during the day?
Experience tension headaches?
Has the patient ever experienced chronic ringing in the ears?
Does the patient need extra help with instructions?
Is the patient sensitive or self-conscious about his/her teeth?
Heights of parents?
Mom & Dad
Are you aware that some appointments will be during school hours?
Benefits
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. ____________________ to perform a complete orthodontic evaluation.
Signature
First Last
Date

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Patient Form (Child)

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Dental History

Benefits