Child Health History (Patients Under 18)

Patient Biographical Information

*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Biological Sex:
*Preferred Pronoun:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell Phone:
Email:
Please list the names of any family currently in the practice:
List any sports, hobbies, or musical instruments played:
School:
Grade:
Has patient begun puberty:

If patient is a girl, has menstruation begun:

If patient is a boy, has their voice changed or have facial hair:

Has the patient grown in the past year or has their shoe size changed recently:

Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Please list the name and birthdate of any siblings:
Father/Guardian Name:
Mother/Guardian Name:
Whom may we thank for referring you to our practice?
Whom does the patient live with?

Dental History

Dentist Name:
Last Dental Visit:
Have you visited an orthodontist in the past?

If so, when?
Explain:
What is your main orthodontic concern?
Please select YES if you have had any of the conditions listed below either now or in the past.
Speech problems/therapy?

Grind or clench teeth?

Oral habits (thumb/finger sucking, lip/nail biting)?

Injury to face, jaw, teeth or mouth?

Sensitive teeth or gums?

Pain, noise, or locking in either jaw?

Mouth breathing?

Snores during sleep?

Requires premedication for dental visit?

Any missing or extra permanent teeth?

Apprehensive about dental care?

Soreness in jaw or face muscles?

Ever been treated for TMJ or TMD?

If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications you are currently taking:
List any allergies or drug sensitivities you may have:
Please select YES if you have had any of the conditions listed below either now or in the past.
Rheumatic Fever, Heart Defect, or Heart Murmur

Lung Disease

Liver Disease

Kidney Disease

Heart Attack/Stroke or Heart Disease

Family History of Jaw Imbalance

Blood Disorder

Hypertension/High Blood Pressure

Immune System Problems

HIV/AIDS

History of Eating Disorder

Tonsils/Adenoids Removed

ADD/ADHD

Cancer

Family History of Cancer

Received Radiation Treatment or Chemotherapy

Endocrine Problems

Hormone Therapy

Latex/Metal Allergy

Mental Health Disturbance

Bone Disorders/Bone Loss

Diabetes

Seizures/Epilepsy or Other Neurological Problems

Been Diagnosed with Sleep Apnea

Asthma

Arthritis

Ever Been Hospitalized

Pneumonia

If any of the above medical questions were answered 'Yes' , please explain:

Primary Responsible Party Information

First Name:
Middle Initial:
Last Name:
*Address:
*City:
*State:
*Zip:
Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Do you have insurance that covers orthodontics?

If so, please name the Insurance Company below:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Secondary Responsible Party Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Do you have insurance that covers orthodontics?

If so, please name the Insurance Company below:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Primary Insurance
Primary Insurance Company
Phone#:
Group #:
Subscriber Name:
Subscriber DOB:
Subscriber #
Subscriber Employer:
Relationship:
Secondary Insurance
Secondary Insurance Company
Phone#:
Group #:
Subscriber Name:
Subscriber DOB:
Subscriber #:
Subscriber Employer:
Relationship:

I authorize Moin Orthodontics to submit insurance claims on my behalf, or my child's behalf if signing for a minor. I authorize the release of any medical or other information necessary to process my claims.

Signature:
Date: