Child Orthodontic Questionnaire

Child Orthodontic Questionnaire

In order for us to properly diagnose and treat our patients, we must have accurate background and health information on which to base our decisions. Please provide the information requested below:
Today's Date:

MonthDayYear
Date
Patient's Name*

First NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age:*
School:*
Grade:*
Parent or Gardian's Drivers License Number:*
Parent or Guardian Email Address*
example@example.com
Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Lives With:*

MotherFatherOther
If "Other" please specify:
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Dentist:*
Patient's Physician:*
Referred By:*
Father's Name:

First NameLast Name
Father's mobile phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Father's Address (if different from patient's address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's SS#:
Father's Date of Birth:

MonthDayYear
Date
Father's Employer:
Father's Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Name of Father's Dental Insurance Company:
Father's Dental Insurance Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Father's Dental Insurance ID:
Father's Dental Insurance Group Number:
Father's Dental Insurance Address PO Box:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name:

First NameLast Name
Mother's mobile phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Address (if different from patient's address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's SS#:
Mother's Date of Birth:

MonthDayYear
Date
Mother's Employer:
Mother's Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Name of Dental Insurance Company:
Insurance Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Insurance ID:
Group Number:
Insurance Address PO Box:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Financially Responsible for the Account:*
Is the Patient Covered By Insurance for Orthodontic Treatment?*

YesNo
Is the Patient Covered By Insurance for TMJ Treatment?*

YesNo
Name of Medical Insurance Company:*
Medical Insurance Company Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance ID:*
Medical Insurance Group Number:*
Medical Insurance Address PO Box:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSTRUCTIONS: the first part of your health questionnaire is designed to help us focus upon your specific concerns. The second part of the questionnaire will allow you to provide any explanations necessary to enhance our overall understanding. Please complete all appropriate answers as accurately as possible. Your confidentiality will be respected.
What are the parent’s or patient’s main concerns regarding the jaws and teeth?*

CrowdingOver-bite"Buck" teethReceded jawProminent jawGummy smileSpacesGum disease/recessionMissing teethJaw dysfunctionMouth too smallClicking jaw jointIrregularly shaped teethProtrusion of teethRinging/Stuffiness of earsHeadaches/facial painNeck painJaw painIrregular facial proportionsOther
Other family members with similar orthodontic condition*

MotherFatherBrotherSisterOther
Patient's marital status (or parent's marital status if patient is a minor)*

MarriedDivorcedSeparatedSingleWidowed
Medical/Dental History
Present Physical Health*

ExcellentGoodFairPoor
Present Emotional Health*

ExcellentGoodFairPoor
If a child; has patient reached puberty?*

YesNo
Has the patient ever had any of the following conditions?*

AIDSAllergiesArteriosclerosisAsthmaAutoimmune disorderBlood diseaseHigh Blood pressureLow blood pressureBone disordersCancerDiabetesDizzinessEpilepsyEndocrine ProblemsEmotional problemHsFemale problemsHepatitisHeart diseaseHearing disorderKidney DiseaseRheumatic feverRinging of earsSleep disturbanceReceived trauma (teeth, face, jaws, or head)Other
Medications
Current medications taken by patient*

Heart pHills (digitalis, etc.)AntibioticsDiet Pills (diuretics)Pain pills (demerol, codiene, etc.)VitaminsBirth control pillsSleeping pillsMuscle relaxantsInsulinNot taking any medicationOther
Alergies to Medication/Food
The patient demonstrates an allergic response to:*

AntibioticsPain pills (codeine, etc.)Dairy ProductsWheat, cerealsDyes in foodN/A
The following are of interest to the orthodontist:
Does the patient drink more than 1 glass of milk per day?*

YesNo
Does the patient have frequent colds?*

YesNo
Does the patient have difficulty chewing?*

YesNo
The following habits are of interest to the orthodontist:
Finger sucking*

NeverPreviouslyPresently
Lip biting or sucking?*

YesNo
Grinding of teeth?*

YesNo
Tongue thrusting?*

YesNo
Smoking?*

YesNo
Please list any other habits that could potentially be of interest to the orthodontist
Patient's or Parent's Attitude toward teeth, face, and Orthodontic Treatment
Dental checkups*

Twice a yearOnce a yearOnly if urgentNever
Are you aware of any orthodontic problems?*

YesNo
Interest in orthodontic treatment*

Wants treatmentTreatment if necessaryUnwilling but agreesUncooperative
Orthodontic consultation prompted by*

PatientDentistMotherFatherSpouseSiblingPhysicianFriendOther
Previous orthodontic consultation or treatment*

YesNo
Any unusual dental experiences?*

YesNo
Are there any medical, dental, or surgical problems not covered above?*

YesNo
If so, please list them here
Why are you seeking this consultation?*

To correct overbiteTo eliminate crowdingto correct jaw disfunction problemTo eliminate facial painTo close spacesTo improve facial proportionsTo improve general appearanceOther
Signature*
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