Child/Adolescent Information

  Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
Sex:
Age:
*Birthdate:    
School:
Grade:
Social Security #:
Email:
*Home Address:  
*City:  
*State:  
*Zip:  
Patient living with:  
Who has legal (medical) authority for patient's treatment:  
*Home Phone:  
   
   
   
Other:  
Other:  
Father's Information
First Name:
Middle Initial:  
Last Name:
Social Security #:
Phone #:
Address:
City:
State:
Zip:
Employer:
Address:
State:
Occupation:  
City:
Zip:
Mother's Information
First Name:
Middle Initial:  
Last Name:
Social Security #:
Phone#:
Address:
City:
State:
Zip:
Employer:
Address:
State:
Occupation:  
City:
Zip:
Is patient adopted?  
Parents Are:  
 
Siblings (name & birthdate):
  Financial Responsible Party Information    
*First Name:  
*Last Name:  
Insurance Father:
Insurance Mother:
*Address:  
*City:  
*State:  
*Zip:  
  Dental/Medical History     
Physician Name:
Dentist Name:
Have you completed all recommended dental work?
Date of last Physical:  
Last Dental Visit:  
How did you come to choose our office? (indicate as many as applicable)
Dentist Referral?
Other family members treated at this office?
Recommendations of neighbors and friends?
Other? (physician, Yellow Pages, dental society, Google, invisalign, etc.)
Insurance Plan Referral?
Names:  
Names:  
Explain:  
  Has pateint had previous orthodontic consultation?
When?  
  Did Father have orthodontic problems?
  Did Mother have orthodontic problems?
Height of Patient:  
Father's Height:  
Describe patient's temperament:  
Do you anticiapte a move or transfer in the near future?
Treatment?  
By? (Dentist, Orthodontist):  
Treated?  
Treated?  
Growth Last Year:  
Mother's Height:  
Patient will probably be:  
What is the patient's (or parent's) primary concern (why are you here?)
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Require antibiotic premedication for dental work
  Birth defects, Congenital Abnormalities
  Heart Trouble/Congenital Heart Lesions
  History of Rheumatic Fever
  High/Low Blood Pressure
  Anemic
  Diabetes
  Fainting/Dizziness
  Epilepsy
  Headaches
  Endocrine/Hormone Disorders
  Allergies to Latex (gloves), Metals, Medications
  Sinus Trouble
  Asthma/Hay Fever
  Infectious Hepatitis/Jaundice/Tuberculosis/Kidney Disease/HIV Positive
  Major Operations or Illnesses
  Speech or Hearing Disorders
  Taking Medication
  Emotional or Psychological Disorder
Dental History
  Growth/Swelling/Sores in Mouth
  Mouth Sensitive to Temperature/Pressure/Food/Drink
  Mouth Breathing
  Bleeding or Swollen Gums
  Tonsils/Adenoid Problems
  Frequent Cold (herpes) or Canker sores
  Habits (Thumb sucking, lip biting, nail biting)
  Injuries to Face, Head or Neck
  Jaw Clicking or Popping while Eating or Yawning
  Difficulty Opening Mouth Widely
  Stiff Neck Muscles
  Clenching or Grinding Teeth
Explain  
Explain  
Explain:  
Explain:  
Controlled:  
Explain:  
Controlled:  
When:  
Medication:  
How often:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
List:  
Explain:  
For How Long:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Please amplify answers if necessary:
Person filling out form: Relationship to Patient:
Today's Date:  
Our Office Policy Is:
The parent who request treatment for the child is responsible for all services rendered. We will however bill either party as a courtesy with this understanding. I also understand that, where appropriate, credit bureau reports may be obtained.