Child Medical/Dental History Form
Patient's Name
*
First Name
Last Name
Name of Person/Persons Completing Form
*
Prefers to be addressed as
Gender
*
Male
Female
Age
*
Birthdate
*
-
Month
-
Day
Year
Date
School
Grade
Patient's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who may we thank for referring you?
What helped you decide to contact Smith & Heymann Orthodontics?
*
Friends
Family
Social Media
Our Website
Online
Reviews
Other
Parent/Guardian 1
Parent/Guardian 1 Name
*
First Name
Last Name
Relationship to Patient
*
Mother
Father
Stepmother
Stepfather
Grandparent
Other
Parent/Guardian 1 Address (If Different than Child's Address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 1 Employer
*
Parent/Guardian 1 Occupation
*
Parent/Guardian 1 Work Phone
Please enter a valid phone number.
Parent/Guardian 1 Email
*
example@example.com
Parent/Guardian 1 Cell Number
*
Please enter a valid phone number.
Preferred way to receive reminders:
Text
Email
Both
Financially responsible for account?
*
Yes
No
Parent/Guardian 2
Parent/Guardian 2 Name
First Name
Last Name
Relationship to patient
Please Select
Mother
Father
Stepmother
Stepfather
Grandparent
Other
Parent/Guardian 2 Home Address (If Different than Child's Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 2 Employer
Parent/Guardian 2 Occupation
Parent/Guardian 2 Work Phone
Please enter a valid phone number.
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Cell Number
Please enter a valid phone number.
Preferred way to receive reminders:
Text
Email
Both
Financially responsible for account?
Yes
No
Parents' Marital Status
*
Single
Married
Divorced
Separated
Widowed
Patient lives with
Mother
Father
Guardian
Stepmother
Stepfather
Grandparent
Primary contact for appointments
Mother
Father
Guardian
Stepmother
Stepfather
Grandparent
Other
Are there other children in the family? If yes, please list their names and ages below.
In Case of Emergency
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Dental Insurance
In order to verify ortho coverage and retrieve benefits, we must have member ID or social if no member id was provided.
Do you have Dental Insurance?
*
Yes
No
If yes, please provide details below.
Policy Holder's Name
First Name
Last Name
Primary Insurance Co
Please provide state if Delta Dental is provider
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
Policy Holder's Employer
SSN/Member ID
SSN/Member ID
Do You Have Ortho Coverage?
Yes
No
Group #
Policy Holder’s Birthdate
-
Month
-
Day
Year
Date
Insured's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance
If you have secondary insurance, please provide details below.
Do you have secondary insurance?
Yes
No
Policy Holder's Employer
Policy Holder's Name
First Name
Last Name
Secondary Insurance Co
SSN/Member ID
SSN
Do You Have Ortho Coverage?
Yes
No
Group #
Policy Holder's Birthdate
-
Month
-
Day
Year
Date
Dental History
Does the patient have a Dentist? If yes, please provide details below.
*
Yes
No
Patient's Dentist Name
Date of Last Visit
-
Month
-
Day
Year
Date
Have there been any injuries to the face, mouth or teeth?
*
Yes
No
Has the patient had or presently have any of the following habits?
*
Thumb or finger sucking
Lip Biting
Snoring
Grinding of the teeth at night
Mouth breathing
None
Does the patient have any missing or extra permanent teeth?
*
Yes
No
Are you aware of sores, lumps or irritated areas in the mouth?
*
Yes
No
Has an orthodontist been consulted previously? If yes, please provide details below.
*
Yes
No
Orthodontist's Name
Date of Last Orthodontic Visit
-
Month
-
Day
Year
Date
Have the patient ever been treated for
*
Bad Bite
TMJ
Periodontal disease
None
Is the patient frightened or anxious about Orthodontic treatment?
*
Yes
No
Are you concerned about the appearance of the patient's teeth?
*
Yes
No
Do the patient have any speech problems?
*
Yes
No
Is there anything you would like to change about the patient's smile?
What aspect of dental treatment are you most concerned with?
*
Quality
Cost
Discomfort
Time
None
Reason for consultation (chief concern)
*
Has there ever been any orthodontic treatment for any other member of your family? If yes, please provide the patient(s) names, their doctor's name, and if the patient was satisfied with treatment.
Doctor Preference
Please Select
Dr. Smith
Dr. Heymann
Dr. Skillestad
Medical History
Is the patient's general health good at this time?
*
Yes
No
Comments
Is the patient under the care of a physician at this time?
*
Yes
No
If yes, please provide details
What is the name of your family physician?
Date of last physical
-
Month
-
Day
Year
Date
Is the patient taking any medication?
*
Yes
No
If yes, please list below.
Are you allergic to any medication?
*
Yes
No
If yes, please list the names of medications the patient is allergic to
Has the patient ever taken any diet medication (Fen-Phen)?
*
Yes
No
Has the patient ever had a serious illness or been hospitalized?
Yes
No
If yes, please explain.
Has the patient had his/her tonsils and/or adenoids removed?
*
Yes
No
If yes, what age?
Does the patient have any special conditions not listed? If yes, please explain
Have the patient ever been advised by your physician to take an antibiotic prior to any dental treatments?
*
Yes
No
If yes, please provide antibiotic name and method.
Does the patient use tobacco? (smoking or chewing)
*
Yes
No
What is the patient's approximate height?
What is the patient's approximate weight?
Does the patient have, or ever had any of the following?
Please check if YES or leave unchecked for NO:
TUBERCULOSIS
ENDOCARDITIS
HEART CONDITION
HEART PACEMAKER
HEART ANGINA
HEART ATTACK (CORONARY)
MITRAL VALVE PROLAPSE
CONGENITAL HEART DISEASE
ARTIFICIAL HEART VALVE
HEART SURGERY
HEART MURMUR
RHEUMATIC FEVER
ARTHRITIS
OSTEOPOROSIS
BISPHOSPHONATES
PROSTHETIC (ARTIFICIAL) JOINT
X-RAY/RADIATION (CANCER) THERAPY
AIDS OR H.I.V. POSITIVE
Please check if YES or leave unchecked for NO:
DIABETES
RESPIRATORY LUNG DISEASE
HIGH BLOOD PRESSURE
LOW BLOOD PRESSURE
HEPATITIS
VENEREAL DISEASE
HERPES (ORAL-COLD SORES)
BLOOD DISORDERS/BLEEDING PROBLEMS
INFLAMMATORY RHEUMATISM
ULCERS
STROKE
ANEMIA
ASTHMA
EPILEPSY
GLAUCOMA
FAINTING SPELLS
Please check if YES or leave unchecked for NO:
ADD
KIDNEY TROUBLE
LIVER DISEASE
PSYCHIATRIC TREATMENT
DRUG ADDICTION
HEADACHES
EARACHES
JAW CLICKING
ALLERGIES
ALLERGIES TO METAL
ALLERGIES TO LATEX
JAW PAIN
TONSILLITIS
EMOTIONAL PROBLEMS
OTHER
HIPAA Consent
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address. I have read the HIPAA Policy and agree to the terms.
*
I agree
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.
Parent/Guardian Signature
*
Submit
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