Child Massillon

Medical/Dental History Form for Patients Under Age 18

American Association of Orthodontists (AAO)
PATIENT INFORMATION
Date Form Completed

MonthDayYear
Date
Name*

First nameMiddle initialPatient's last name
Preferred name
Birth date*

MonthDayYear
Date
Sex

MaleFemale
School
Grade
Preferred Email Address for correspondence*
Home Address*

Street

Street Address Line 2

City, State, Zip codeState / Province

Postal / Zip Code
Home phone*
Preferred cell phone number for text reminders*
PARENT/GUARDIAN
Custodial parent(s) name(s)*
Patient lives with (check all that apply)

MotherFatherStepfatherStepmotherGrandparent(s)Other
Father's full name
Address (if different)
Cell phone
Occupation
Email address
Mother's full name
Address (if different)
Cell phone
Occupation
Email address
DENTIST INFORMATION
Patient's Dentist*
Address, City, State
Last scheduled visit
Reason
Other dentists/dental specialists now being seen:
Name
City, State
Reason
GENERAL INFORMATION
What concerns you about your child's teeth?
What concerns your child about his/her teeth?
How does your child feel about orthodontic treatment?
Who suggested that your child might need orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultations.
Does your child play a musical instrument?
Have any other family members been treated in our office? Please name them.
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Who will be responsible for bringing the patient to orthodontic appointments?
DENTAL INSURANCE
Primary policy holder's full name
Birth date

MonthDayYear
Date
Relationship to patient
Social Security #
Employer
Insurance company
Group #
ID#
Insurance company telephone number
Does this policy have orthodontic benefits?

YesNoDon't Know
Secondary policy holder's full name
Birth date

MonthDayYear
Date
Social Security #
Relationship to patient
Employer
Insurance company
Group #
ID#
Insurance company telephone number
Does this policy have orthodontic benefits?

YesNoDon't Know
PHYSICIAN
Patient's Physician
City, State
Last visit
Reason for last visit
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
MEDICAL HISTORY

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.

Now, or in the past, has your child had (please click all that apply):*

	Yes	No
Birth defects or hereditary problems
Injuries to face, head, neck
Arthritis or joint problems
Cancer, tumor, radiation treatment or chemotherapy
Endocrine or thyroid problems
Diabetes or low sugar
Kidney problems
Immune system problems
Hepatitis, jaundice, or other liver problems
Polio, mononucleosis, tuberculosis, pneumonia
Seizures, fainting spells, neurologic problems
Mental health disturbance or depression
History of eating disorder (anorexia, bulimia)
Frequent headaches or migraines
High or low blood pressure
Excessive bleeding or bruising, anemia
Heart defects, heart murmur, rheumatic heart disease
Skin disorder (other than common acne)
Vision, hearing, or speech problems
Frequent ear infections, colds, throat infections
Tonsil or adenoid condition
Frequently breathes through his/her mouth

Is there a medical condition NOT listed above that we should know about prior to orthodontic treatment? Please type in below.
Has your child had allergies or reactions to any of the following:

Local anesthetics (novocaine, lidocaine, xylocaine)Latex (gloves, balloons)AspirinIbuprofen (Motrin, Advil)PenicillinOther antibioticsMetals (jewelry, clothing snaps)AcrylicsPlant pollensAnimalsFoodsOther
Is there an allergy NOT listed above that we should know about prior to orthodontic treatment? Please type in below.
DENTAL HISTORY

Now, or in the past, has your child had (please click all that apply):*

	Yes	No
Erupting teeth--very early or very late
Primary (baby) teeth removed that were not loose
Permanent or extra (supernumerary) teeth removed
Supernumerary (extra) or congenitally missing teeth
Any sensitive or sore teeth
Any lost or broken fillings
Jaw fractures, cysts, infections
Any teeth treated with root canals or pulpotomies
Frequent canker sores or cold sores
History of speech problems or speech therapy
Difficulty breathing through nose
Mouth breathing habit or snoring at night
Frequent oral habits (sucking finger, chewing pen, etc.)
Teeth causing irritation to lip, cheek or gums
Tooth grinding or clenching
Clicking, locking jaw joints
Soreness in jaw muscles or face muscles
Has your child been treated for "TMJ" or "TMD" problems
Any broken or missing fillings
Any serious trouble associated with previous dental treatment
Diagnosed with gum disease or pyorrhea

Is there another dental issue NOT listed above that we should know about prior to orthodontic treatment? Please type in below.
How often does your child brush?
How often does your child floss?
PATIENT HEALTH INFORMATION
Do you think that any of your child's activities affect his/her face, teeth or jaws? How?
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.
Does your child take antibiotic pre-medication before any dental procedures?

YesNo
If "yes" above, why is the pre-medication requested by physician?
Have you noticed any unusual changes in your child's face or jaws?

YesNo
If "yes" above, briefly describe these changes.
Any other physical problems that you think could affect orthodontic treatment?
FAMILY MEDICAL HISTORY
Have the parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disordersArthritisUnusual dental problemsDiabetesSevere allergiesJaw size imbalanceCongenitally missing teethOther
RELEASE AND WAIVER
I authorize release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors oromissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child's medical or dental health.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical/Dental History Form for Patients Under Age 18

PATIENT INFORMATION

PARENT/GUARDIAN

DENTIST INFORMATION

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

PHYSICIAN

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER