Child Health Form
About Your Child
Name
*
First Name
Last Name
Preferred Name
Gender
*
Male
Female
Birthdate
-
Month
-
Day
Year
Date
Age
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade
Hobbies/Sports
Musical Instruments
General Information
Who is accompanying this child today?
Name
*
First Name
Last Name
Relation
*
Legal Guardian
*
Yes
No
Who is financially responsible for the account?
*
Who is responsible for making appointments?
*
Parents' Marital Status
Single
Married
Divorced
Widowed
Separated
Child's Medical History
Physician's Name
Phone Number
Please enter a valid phone number.
Last Visit
-
Month
-
Day
Year
Date
Child's Physical Health is
*
Good
Fair
Poor
Height
*
Weight
*
Is your child currently being treated by a physician?
*
Yes
No
If yes, please explain
Has your child had any metal rods, pins or implants?
*
Yes
No
Please list any prescriptions or over-the-counter drugs your child takes and teh reason for the medication:
Has your child ever taken Fosamax, Actonel, Boniva, or any other for of Bisphosphonate?
*
Yes
No
Are your child's immunizations current?
*
Yes
No
Anything you would like to discuss with the doctor in private?
*
Yes
No
Females Only:
Has she begun menstruation?
Yes
No
Does she take birth control?
Yes
No
Is she pregnant?
Yes
No
Parent's Information
Which option best describes the father?
Father
Step Father
Guardian
Other
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
SSN#
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method
Home Phone
Cell Phone
Work
Email
Text
Employer
How Long There?
Occupation
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Orthodontic Benefits?
Yes
No
Unsure
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Insurance ID Number
Mother's Information
Which option best describes the mother?
Mother
Step Mother
Guardian
Other
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
SSN#
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Preferred Contact
Home
Cell
Work
Email
Text
Employer
How Long There?
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Orthodontic benefits?
Yes
No
Unsure
Insurance Company
Insurance Phone Number
Please enter a valid phone number.
Insurance ID #
Child's Allergies
Does your child have any allergies?
*
Yes
No
If yes, please select all that apply
Aspirin
Metals/Nickel
Advil/Ibuprofen
Penicillin
Latex
Codeine
Dogs
Please list any other allergies or reactions
Has your child ever had any of the following? Please select all that apply
ADD/ADHD
Autism Spectrum/Asperger's
AIDS/HIV
Artificial Joints/Valves
Asthma
Bed Wetting
Cancer
Canker/Cold Sores
Colitis
Congenital Heart Defect
Diabetes
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Handicap/Disability
Hay Fever
Hearing Impairment
Heart Surgery
Heart Murmur
Hemophilia/Blood Disorder
Hepatitis
Herpes/Fever Blisters
Hospital Stay/Operations
High Blood Pressure
Large Tonsils
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Prosthetic
Psychiatric Problems
Rheumatic/Scarlet Fever
Seizures/Convulsions
Sickle Cell Disease/Trait
Sinus Problem
Thyroid Problems
Tuberculosis (TB)
Ulcers
List any concerns you have about your child's smile and/or bite
Prior history of orthodontic treatment
Who may we thank for referring you to our office?
Other family members seen by us
Does your child have any of the following habits? (Please select all that apply)
Thumb/Finger Sucking
Lip Sucking/Biting
Nail Biting
Tongue Thrust
General/Pediatric Dentist
Last Visit
-
Month
-
Day
Year
Date
Has your child ever been evaluated by an orthodontist?
*
Yes
No
Does your child have any missing permanent teeth?
*
Yes
No
Does your child brush their teeth twice daily?
*
Yes
No
Family history of jaw surgery for bite correction?
*
Yes
No
History of speech problems?
*
Yes
No
Does your child commonly snore?
*
Yes
No
History of major trauma/injury of the face, jaw, teeth or mouth?
*
Yes
No
Does your child grind their teeth?
*
Yes
No
Does your child grind their teeth?
*
Yes
No
Has your child ever been treated for TMJ/TMD?
*
Yes
No
Does your child have pain in their jaw joints?
*
Yes
No
Does your child's jaw routinely pop or click?
*
Yes
No
Has your child's jaw ever locked open or closed?
*
Yes
No
Does your child experience pain in their ears?
*
Yes
No
Have adenoids and/or tonsils been removed?
*
Yes
No
Which does your child do?
*
Breathes through mouth
Breathes through nose
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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