Smith + Heymann Ortho Child Medical/Dental History Form

  • Child Medical/Dental History Form

  • Gender*
  • Birthdate*
     - -
  • What helped you decide to contact Smith & Heymann Orthodontics?*

  • Parent/Guardian 1

  • Relationship to Patient*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred way to receive reminders:
  • Financially responsible for account?*

  • Parent/Guardian 2

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred way to receive reminders:
  • Financially responsible for account?
  • Parents' Marital Status*
  • Patient lives with
  • Primary contact for appointments

  • In Case of Emergency

  • Format: (000) 000-0000.

  • 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?*

  • If yes, please provide details below.

  • Do You Have Ortho Coverage?
  • Policy Holder’s Birthdate
     - -

  • Secondary Insurance

    If you have secondary insurance, please provide details below.
  • Do you have secondary insurance?
  • Do You Have Ortho Coverage?
  • Policy Holder's Birthdate
     - -

  • Dental History

  • Does the patient have a Dentist? If yes, please provide details below.*
  • Date of Last Visit
     - -
  • Have there been any injuries to the face, mouth or teeth?*
  • Has the patient had or presently have any of the following habits?*
  • Does the patient have any missing or extra permanent teeth?*
  • Are you aware of sores, lumps or irritated areas in the mouth?*
  • Has an orthodontist been consulted previously? If yes, please provide details below.*
  • Date of Last Orthodontic Visit
     - -
  • Have the patient ever been treated for*
  • Is the patient frightened or anxious about Orthodontic treatment?*
  • Are you concerned about the appearance of the patient's teeth?*
  • Do the patient have any speech problems?*
  • What aspect of dental treatment are you most concerned with?*

  • Medical History

  • Is the patient's general health good at this time?*
  • Is the patient under the care of a physician at this time?*
  • Date of last physical
     - -
  • Is the patient taking any medication?*
  • Are you allergic to any medication?*
  • Has the patient ever taken any diet medication (Fen-Phen)?*
  • Has the patient ever had a serious illness or been hospitalized?
  • Has the patient had his/her tonsils and/or adenoids removed?*
  • Have the patient ever been advised by your physician to take an antibiotic prior to any dental treatments?*
  • Does the patient use tobacco? (smoking or chewing)*

  • Does the patient have, or ever had any of the following?

  • Please check if YES or leave unchecked for NO:
  • Please check if YES or leave unchecked for NO:
  • Please check if YES or leave unchecked for NO:

  • HIPAA Consent

  • 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.
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