Child Health History
Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
Age:
*Gender:
Male
Female
Please list the names and ages of siblings:
Whom may we thank for referring you?
Parent or Legal Guardian Information
Parents' Marital Status:
Married
Single
Divorced
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
How long at this address?
Own
Rent
Email:
*Main Phone:
Social Security #:
*Birthdate:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
*Address:
*City:
*State:
*Zip:
How long at this address?
Own
Rent
Email:
*Main Phone:
Social Security #:
Birthdate:
Employer:
Occupation:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental Insurance Information
Name of Insured:
Date of Birth:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Name of Ins. Company:
Insurance Co. Address:
Insurance Co. Phone:
Subscriber/Policy #:
Group #:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
By whom?
Main orthodontic concern:
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
Yes
No
Grind or clench teeth?
Yes
No
Oral habits (thumb/finger sucking, lip/nail biting)?
Yes
No
Injury to face, jaw, teeth or mouth?
Yes
No
Discomfort from teeth or gums?
Yes
No
Pain, tenderness or noise in either jaw?
Yes
No
Mouth breathing?
Yes
No
Snores during sleep?
Yes
No
Any missing or extra permanent teeth?
Yes
No
Apprehensive about dental care?
Yes
No
Requires premedication?
Yes
No
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Patient Health:
Good
Excellent
Fair
Poor
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Latex/Metal Allergy
Yes
No
Rheumatic Fever
Yes
No
Tuberculosis/Lung Disease
Yes
No
Pneumonia
Yes
No
Liver Disease
Yes
No
Kidney Disease
Yes
No
Heart Attack/Stroke
Yes
No
Heart Disease
Yes
No
Congenital Heart Defect
Yes
No
Heart Murmur
Yes
No
Hemophilia
Yes
No
Hypertension/High Blood Pressure
Yes
No
Prolonged Bleeding/Transfusion
Yes
No
Anemia
Yes
No
HIV/AIDS
Yes
No
Hepatitis
Yes
No
Cancer
Yes
No
Received Radiation Treatment
Yes
No
Growth Problems
Yes
No
Endocrine Problems
Yes
No
Hormone Therapy
Yes
No
Nervous Disorders
Yes
No
Bone Disorders/Bone Loss
Yes
No
Diabetes
Yes
No
Seizures/Epilepsy
Yes
No
Handicaps/Disabilities
Yes
No
Asthma
Yes
No
Arthritis
Yes
No
Treated for Emotional Problems
Yes
No
Ever Been Hospitalized
Yes
No
Smoke or use Tobacco
Yes
No
Tonsils/Adenoids Removed
Yes
No
Is there any other condition or problem that you think we should know about?
Do you wish to receive appointment confirmations via email?
Yes
No
Do you wish to receive text message appointment confirmations?
Yes
No