YOUTH HEALTH HISTORY FORM
*Patient's Name: (LAST, FIRST, MI)
*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:
Father's Name:
Address:
Social Security #:
Birthdate:
Home Phone:
Cell:
Email:
Employer:
Occupation:
Employer Address:
Work Phone:
Mother's Name:
Address:
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?
Primary Dental Insurance Company & Address:
Subscriber's Name:
Subscriber's Social Security Number:
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 Number:
Relationship to Patient:
Subscriber's Address:
Subscriber's Birthdate:
Subscriber's Employer:
Subscriber's ID:
Subscriber's Group #:
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 does your child feel about wearing braces?
Has your child 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:
Patient's Physician:
Approximate date of last physical:
Are currently seeing a Physical Therapist or Chiropractor?
If yes, Name & Address:
Is the patient currently in good physical health? If no, briefly explain below:
Please list any medications patient is currently taking:
List any drug allergies or sensitivities patient 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:
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.