Dunn Orthodontics Child Health History

*First Name:

Middle Initial:

*Last Name:

Nickname:

*Address:

*City:

*State:

*Zip:

*Home Phone:

Work Phone:

Mobile/Alt. Phone

*Gender:

Age

*Birthdate:

School

Grade

Preferred Office Location

Email

Who should be contacted for appointments and scheduling?

With whom does the patient live?

Is the patient information the same as the parents'?

Yes No

Father's First Name

Father Middle Initial

Father's Last Name

*Address:

*City:

*State:

*Zip:

Rent Own

How long at this address?

Previous Address

Occupation

Employer

Yrs with Current Employer

Social Security #

Date of Birth

Home Phone

Work Phone

Mobile/Alt Phone

Mother's First Name

Mother's Middle Initial

Mother's Last Name

*Address:

*City:

*State:

*Zip:

Rent Own

How long at this address?

Previous Address

Occupation

Employer

Yrs with Current Employer

Social Security #

Date of Birth

Home Phone

Work Phone

Mobile/Alt Phone

*First Name:

Middle Initial:

*Last Name:

Is there an Insurance Company that we can contact concerning orthodontic coverage?

Yes No

Insurance Company Name

Group Number

Address where claims are filed

Insured's Name

SS#

Date of Birth

Insurance Company Name

Group Number

Address where claims are filed

Insured's Name

SS#

Date of Birth

Dentist Name:

When was your last general dental exam?

Physician Name:

Whom may we thank for referring you?

Please check any of the folowing which the patient has had or presently has

Abnormal Bleeding/Hemophilia

Hay Fever

Stroke

Glaucoma

Angina Pectoris

Sinus Trouble

Blood Transfusion

Ulcers

High Blood Pressure

Allergies/Hives

Heart Disease

Excessive Bleeding

Heart Murmur

Diabetes

Bruise Easily

Pain/Noises in Jaw Joint

Rheumatic Fever

Thyroid Disease

Anemia

Emphysema

Congenital Heart Problems

Scarlet Fever

Arthritis

Chronic Cough

Artificial Heart Valve

Cancer

Artificial Joint

Tuberculosis

Heart Pacemaker

Liver Disease

Rheumatism

HIV+ or AIDS

Heart Surgery

Hepatitis A

Kidney Trouble

Venereal Disease

X-ray/Cobalt Treatment

Hepatitis B

Cortisone Medication

Cold Sores

Eplilepsy/Seizures

Yellow Skin/Jaundice

Psychiatric Treatment

Genital Herpes

Fainting/Dizzy Spells

Sickle Cell Disease

Does the patient have any disease or condition not listed? If so, please list:

Has the patient been hospitalized during the last two years?

Yes No

Has the patient been under a physician's care in the last two years for a specific illness?

Yes No

Has the patient taken any medications in the last two years?

Yes No

Please list:

Do you require medication prior to dental visits?

Yes No

Is the patient allergic to or made sick by any medications?

Penicillin

Aspirin

Codeine

Other:

Female patients: Are you pregnant?

Yes No

Does patient currently suck a finger, lip, or tongue?

Yes No

Does the patient grind or clench their teeth at night?

Yes No

Does patient frequently breathe through their mouth?

Yes No

Has the patient been treated for respiratory problems?

Yes No

Is the patient interested in changing the appearance of their teeth or face?

Yes No

What is the patient's attitude toward braces?

MALE PATIENTS: Has his voice begun to change?

Yes No

Has he started to shave?

Yes No

FEMALE PATIENTS: Has she started her monthly period?

Yes No

If so, when?

Has the patient experienced a sudden increase in height?

Yes No

About how much?

Over what period of time?

Father's height

Mother's height

Patient's height

Siblings' ages and heights

a.

DOB:

Age:

Height:

b.

DOB:

Age:

Height:

c.

DOB:

Age:

Height:

Do you realize that some appointments must be scheduled during school hours?

Yes No

To the best of my knowledge, these answers are true and correct. If I ever have any change in my health, or if my medications change, I will inform the orthodontist at my next appointment.

Patient Biographical Information

Financial Party Information

Medical and Dental History Information