Child Health History Form

Child Health History Form
About Your Child
Patient's Name *

First Name Last Name
Preferred Name/Nickname
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell # for Text Confirmation *

Area Code Phone Number
Carrier *
Owner of Phone *
Child's DOB *
Age *
Sex *

Male Female
School
Grade
Parents or Guardians
Patient Lives With: *

Both Parents Together Both Parents Separately Mother Father
Father/Guardian *

First Name Last Name
Employer *
Cell Phone *

Area Code Phone Number
Mother/Guardian *

First Name Last Name
Employer *
Cell Phone *

Area Code Phone Number
Parent Address (if different than Patient's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address
How did you hear about our office? *
What is the reason you are seeking an orthodontic evaluation? *
Has an orthodontist been consulted previously? *

Yes No
Reason
Medical Health Information
Is patient adopted? *

Yes No
If yes, at what age?
Name of child's physician *
Physician's phone number *

Area Code Phone Number
Does your child have or has he/she had any of the following diseases or conditions? (Check all that apply)

Diabetes Stroke Asthma Hepatitis Tonsillitis Fainting Spells, Seizures Scarlet Fever Rheumatic Heart Disease Allergies (medicine or other) Latex or Nickel Sensitivity/Allergy High or Low Blood Pressure Tonsils/Adenoids Removed AIDS, HIV Positive Herpes, Fever Blisters Joint Replacement or Implant Excessive Bleeding or Bruising Drug or Alcohol Dependency Heart Defect, Heart Murmur, Heart Disease
Does this patient now or has he/she ever taken bisphosphonates, inculding Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid, or Zometa? *

Yes No
If yes, which drug?
If patient is female, has she begun menstruating? *

Yes No
Does your child have any disease, condition, or problem not listed that you think we should know about? Please explain: *
Is your child taking any medication at this time? *

Yes No
If yes, please list
Dental Insurance Information
Primary Insurance Company Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group/Plan Number *
Primary Policy Holder Name *
Social Security Number *
Policy Holder's DOB *

Month Day Year
Date
Secondary Insurance Company
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group/Plan Number
Secondary Policy Holder Name
Social Security Number
Policy Holder's DOB

Month Day Year
Date
Do you participate in a flex plan?

Yes No
Dental Health Information
Does your child have any cavities that you know of? *

Yes No
Estimated date of last dental visit (Month and Year) *
How often does your child brush and floss?
Brush per day *
Floss per week *
Dentist's Name *
Dentist's Phone Number

Area Code Phone Number
Dentist's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Does your child have or has she/he had any of the following diseases or problems: (check all that apply)

Snoring, Sleep Apnea Jaw Pain (Joint, Ear, Side of Face) Difficulty Chewing Finger or Lip Sucking Habit Chronic Mouth Breathing Tooth Sensitivity to Heat, Cold or Sweets Missing Permanent Teeth Clicking or Popping of the Jaw Joints
Personal Information
Does the patient have any siblings? *

Yes No
If yes, what are their ages?
Please list any special interests of the patient (sports, hobbies, etc) *
Patient's attitude toward orthodontic treatment *

Very Motivated Will Cooperate (if needed) Not Motivated
Photo Release
I hereby consent to and authorize the use and reproduction, in print or electronic format by Local Orthodontics, of any and all photographs which have been taken for any marketing/advertising purposes, without compensation. All images are owned by Local Orthodontics. *

Accept Decline
I acknowledge that the above information is correct. I will notify Dr. Jewett of any changes that occur after this date. I hereby authorize Dr. Jewett and his team to perform an initial orthodontic evaluation/examination.
Parent/Guardian Signature

Clear
Parent/Guardian Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

Child Health History Form

About Your Child

Parents or Guardians

Medical Health Information

Dental Insurance Information

Dental Health Information

Personal Information

Photo Release