Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
Likes to be called:
*Birthdate:
*Gender:
Male
Female
Is patient adopted?
Y
N
At what age?
*Address:
*City:
*State:
*Zip:
*Home #:
School:
Grade:
Hobbies/Sports Activities:
Please list the names and ages of other children in family:
1
M
F
Age:
4
M
F
Age:
2
M
F
Age:
5
M
F
Age:
3
M
F
Age:
6
M
F
Age:
Whom may we thank for referring you to our practice?
Dentist:
Person accompanying patient:
Relationship:
Do you have custody of this child?
Y
N
Responsible Party Information
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Length of Employment:
Work Phone #:
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
Cell #:
Email:
Employer:
Occupation:
Length of Employment:
Work #:
Dental Insurance Information
Subscriber's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Subscriber's Employer:
Do you have dual dental coverage?
Y
N
(If yes, complete information below)
Subscriber's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Subscriber's Employer:
Medical/Dental History
What is the main orthodontic concern at this time?
What would you like orthodontic treatment to accomplish?
Child's attitude toward orthodontic treatment:
Very Motivated
Will cooperate if needed
Not Motivated
Y
N
Does your child see a dentist on a regular basis? Last Dental Visit:
Y
N
Has your child been evaluated or had orthodontic treatment before? Where?
Y
N
Has there been any injury to the mouth, face, teeth, or chin? Date:
Y
N
Are you aware of any missing teeth/extra permanent teeth? List:
Y
N
Has your child had any teeth extracted? If so, why?
Y
N
Any habits?
Thumb
Finger
Lip
sucking or
Fingernail
Pencil
Lip
biting? To what age?
Y
N
Has your child ever had any noise, pain, stiffness, or difficulty openning in the jaw joint (TMJ/TMD)?
Y
N
Has your child ever been treated for a jaw joint problem?
Y
N
Any difficulty chewing or swallowing?
Y
N
Are you aware of any clenching/grinding of your child's teeth during the day/night?
Y
N
Does your child brush their teeth daily?
Y
N
Does your child floss daily?
Does your child generally breath through their
Nose
Mouth
?
Does your child have allergies/hayfever?
Seasonal
Year Round
Y
N
Have the adenoids and/or tonsils been removed? Date:
Y
N
Is your child in good health?
Y
N
Any changes in your child's health in the past year?
Physician Name:
Phone:
Last Visit Date:
Any medications (over-the-counter/prescription) currently being taken? Please list with reason:
Please list all allergies (including drug allergies):
Has patient begun puberty?
Y
N
If patient is a girl, has menstruation begun:
Y
N
Please select YES or No for the Following Questions - Do Not Leave Blank
Y
N
Rheumatic Fever
Y
N
Tuberculosis/Lung Disease
Y
N
Pneumonia
Y
N
Liver Disease
Y
N
Kidney Disease
Y
N
Heart Attack/Stroke
Y
N
Heart Disease
Y
N
Congenital Heart Defect
Y
N
Heart Murmur
Y
N
Hemophilia
Y
N
Hypertension/High Blood Pressure
Y
N
Prolonged Bleeding/Transfusion
Y
N
Anemia
Y
N
HIV/AIDS
Y
N
Hepatitis
Y
N
Tonsils/Adenoids Removed
Y
N
Cancer
Y
N
Family History of Cancer
Y
N
Received Radiation Treatment
Y
N
Growth Problems
Y
N
Endocrine Problems
Y
N
Hormone Therapy
Y
N
Latex/Metal Allergy
Y
N
Nervous Disorders
Y
N
Bone Disorders/Bone Loss
Y
N
Diabetes
Y
N
Seizures/Epilepsy
Y
N
Handicaps/Disabilities
Y
N
Asthma
Y
N
Arthritis
Y
N
Treated for Emotional Problems
Y
N
Ever Been Hospitalized
Explain yes answers:
Other disease, condition, serious illness or problem not listed here we should know about?
I understand that the information that 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 I understand it is my responsibility to inform this office of any changes in my child's medical status. This office reserves the right to obtain a credit bureau report for the purpose of considering payment options.