YOUTH HEALTH HISTORY

Confidential Youth Patient Information

* Last Name:
* First Name:
Middle Name:
* Address:
* City:
* State:
* Zip:
Nickname:
* Birthdate:
Age:
* Sex:
Phone number we should use to confirm appointments:
Email address we can use for appointment reminders:
Text number we can use for appointment reminders:
Whom may we thank for referring you to our practice?
Patient's hobbies/interests:

Parent & Responsible Party Information

Father's Information
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip:
Social Security #:
Birthdate:
Home Phone:
Cell:
Email:
Employer:
Occupation:
Employer Address:
Work Phone:
Mother's Information
Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip:
Social Security #:
Birthdate:
Home Phone:
Cell:
Email:
Employer:
Occupation:
Employer Address:
Work Phone:

If divorce is involved, who is the custodial parent?
May patient information be released to the non-custodial parent?

Insurance Information

Primary Dental Insurance Company & Address:
Subscriber's Name:
Subscriber's Social Security #:
Relationship to Patient:
Subscriber's Address:
Subscriber's Birthdate:
Subscriber's Employer:
Subscriber's ID:
Subscriber's Group #:
Secondary Dental Insurance Company & Address:
Subscriber's Name:
Subscriber's Social Security #:
Relationship to Patient:
Subscriber's Address:
Subscriber's Birthdate:
Subscriber's Employer:
Subscriber's ID:
Subscriber's Group #:

Dental History

What is your child's main orthodontic problem as you see it?
Is your child sensitive about the appearance of his/her teeth?
Is your child sensitive about the appearance of any facial features? (nose, chin, lips, etc.)
How do you feel about wearing braces?
Have you ever had an orthodontic consultation?
Has anyone in the family received orthodontic treatment?
If yes, who?
Name of your general dentist:
Frequency of dental checkups:
Date of last dental exam:

Answer yes or no if applicable now or in the past:
* Apprehensive about dental care
* Jaw joint sounds
* Difficulty chewing or opening
* Brush teeth daily
* Jaw joint pain
* Cysts or mouth infections
* Floss teeth daily
* Jaw "tires" when eating
* Fluoride treatments
* Jaw catches when opening
* Previous orthodontic therapy
* Jaw locks in closed position
* Frequent canker sores
* Jaw locks in open position
* Speech therapy
* Thumb/finger sucking habit
* Jaw pain or ringing in ears
* Frequently chews gum
* Wake up with sore teeth
* Had periodontal treatment
* Gag reflux
* Discomfort from teeth or gums
* Bleeding gums
* Wake up with sore jaw
* Body piercing
* Snores when sleeping
* Oral surgery
* Teeth that are shifting
* Mouth breathing
* Any missing permanent teeth
* Any injuries to face, mouth, teeth
* Sleeps with mouth open
* Injury to teeth
* Grinding of teeth
* Injury to either jaw
* Frequent clenching of teeth
* Other
If you answered yes to any of the above, please explain:

Medical History

Patient's Physician:
Approximate date of exam:
Are currently seeing a Physical Therapist or Chiropractor?
If yes, Name & Address:
Are you currently in good physical health?
If no, briefly explain below:
Please list any medications you are currently taking:
List any drug allergies or sensitivities you may have:

Answer yes or no if applicable now or in the past:
* Allergies (latex-gloves/ballons)
* Allergies (metals-jewelry/clothing)
* Allergies (acryilic)
* Allergies (medication)
* Allergies (food)
* Allergies (seasonal)
* Enlarged tonsils
* Tonsils or adenoids removed
* Frequent sore throats
* Cleft palate/lip
* Asthma
* Anemia
* HIV/AIDS
* Radiation treatment
* Cancer
* Family history of cancer
* Bone disorder/bone loss
* Immunodeficiency
* Endocrine problems
* Heart murmur
* Heart attack/stroke
* Congenital heart defect
* Hormone therapy
* Diabetes
* Hepatitis
* Rheumatic fever
* Tuberculosis
* Heart disease
* Liver disease
* Kidney disease
* Lung disease
* Pneumonia
* Arthritis
* Emotional problems
* Pyschological counseling
* Handicaps/disabilities
* Requires premedication
* Ever been hospitalized
* Tobacco use
* Bottle-fed
* Breastfed
* Born premature
* Hemophilia
* Are you pregnant? (females)
* Right or left handed
* Facial pain
* Frequent headaches
* Tongue thrust
* Back or neck injuries
* Back, neck or shoulder pain
* Frequent Nausea
* Dizziness
* Balance issue
* Scoliosis
* Growth problems
* Ear pressure
* Foot/Ankle sprain
* Knee, hip, foot pain
* ADHD
* Autism
* Nervous disorder/anxiety
* Intermittent blurred vision
* Tone/Ringing in ears
* Torticollis
* Loss of place when reading
* Hypersensitivity (light, sound, movement)
* Difficulty with comprehension or mental fog
* Hypertension/high blood pressure
* Frequent or large changes in vision
* Other
If any of the above medical questions were answered 'Yes' , please explain:

Genetic History

Height:
Weight:
School:
Grade:
Has the patient's shoe size changed recently:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed:
Is the patient adopted?
If yes, is the patient aware of this?
Does any genetically related family member have a similar facial/dental appearance?
List name(s) and birthdate(s) of siblings:
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.