Child Med HX Form

Child Form

Welcome to our office. The following information will enable us to provide you an accurate evaluation of your orthodontic problem during your initial examination in our office. This information, which is important for our records and your health, is confidential.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Tel. Number to reach you (During Business Hours)*
Please enter a valid phone number.
Email*
example@example.com
Family Dentist
Family Physician
School Name
City of your school
What grade are you in?
Family History
Patient lives with*

Both parents togetherBoth parents separatelyOther
If you chose other, please explain
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.
Parent/Guardian #1 E-mail
example@example.com
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.
Parent/Guardian #2 E-mail
example@example.com
Person financially responsible for account*

First NameLast Name
Names and ages of brothers and sisters
Please list other immediate family members seen in our office
Medical History
General Health*

ExcellentGoodFairPoor
Presently under medical care for
Medication currently being taken (drug and dose)
Allergies (latex, metals, acrylic, medications)
Birth defects or hereditary problems
Are you pregnant or suspect you may be?*

YesNoN/A
If yes, what is the expected delivery date?

MonthDayYear
Date
Have you been advised to take antibiotics before a dental appointment?*

YesNo
Have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid or Zometa?*

YesNo
Please check all that apply to you*

Adenoids (removed)ArthritisAsthmaBlood/bleeding disordersBone disordersDiabetesEar, nose, throat conditionEmotional disorderEndocrine, thyroid problemsEpilepsy, seizuresFainting or dizzy spellsGlaucomaHayfever, sinus troubleHeart disorder/murmurHepatitis, liver problemHigh/Low blood pressureHIV positive or AIDSHospitalizedLung disorderRheumatic feverScoliosisSpeech difficultyTonsils (removed)TuberculosisNone of the above
Are there any medical conditions we have not discussed that you feel we should be aware of?*

YesNo
If yes, please describe
Smile Esthetics
Is there anything about your smile or teeth that you don’t like, would like to change, or would like us to know about?
When was the last dental check-up?

MonthDayYear
Date
Dental History
Do you hear noises in your jaw joints?*

YesNo
Do you experience pain in or about the ears, temples, or cheeks?*

YesNo
Do you experience soreness, stiffness or fatigue of the muscles of the face?*

YesNo
Do you experience difficulty, pain or both when chewing, talking, or using your jaws?*

YesNo
Have you had any injuries to your head, neck, or jaw?*

YesNo
Have any teeth been injured due to accidents to the mouth?*

YesNo
If yes, please describe
Do any of the teeth ache?*

YesNo
Have you received or been requested to receive speech correction?*

YesNo
Have you ever had any type of thumb/finger sucking habit or tongue habit?*

YesNo
Have you had other habits (lip biting, nail biting, etc.)?*

YesNo
Do your gums bleed when you brush your teeth?*

YesNo
Have you had any periodontal (gum) problems in the past?*

YesNo
Have you ever had any previous orthodontic treatment (braces, Invisalign)?*

YesNo
If yes, when?
Are you being followed up by any other Dental Specialist?*

YesNo
If yes, what is the Dental Specialist's name?
Do you smoke?*

YesNo
If yes, how much?
Do you use e-cigarettes, vape or use a Juul?*

YesNo
Has your Dentist ever recommended a night guard?*

YesNo
Is there a family history of sleep apnea?*

YesNo
How often do you brush your teeth?*

2-3x/dayOnce a day“what’s a toothbrush?”
How often do you floss your teeth?*

1-2x/dayOccasionallyRarely
Whom may we thank for referring you to our office?*
Airway/Breathing Questionnaire
While sleeping, does your child… (Choose all that apply)*

SnoreMove (toss and turn) a lotClench or grind their teethHave “heavy” or loud breathingHave trouble breathing or struggle to breatheNone of the above
Have you ever… (Choose all that apply)*

Seen your child stop breathing during the nightBeen told by a teacher that your child appears sleepyFound it hard to wake your child up in the morningNone of the above
Does your child… (Choose all that apply)*

Tend to breathe through the mouth during the dayExperience chronically dry, chapped lipsHave a dry mouth on waking up in the morningOccasionally wet the bedWake up feeling un-refreshed in the morningHave a problem with sleepiness during the dayFind it hard to wake up in the morningWake up with headaches in the morningExperience frequent ear infections, sore throats and tonsillitisNone of the above
This child often… (Choose all that apply)*

Does not seem to listen when spoken to directlyHas difficulty organizing tasksIs easily distracted by extraneous stimuliFidgets with hands or feet or squirms in seatNone of the above
I authorize Wilk & Wilk Orthodontics to use the email address provided above for the purposes of maintaining correspondence concerning treatment, account balances, office events, educational information relating to orthodontics, and appointment reminders.
Questionnaire completed by*

First NameLast Name
Relation to patient*
Signature*

Clear
Date*

MonthDayYear
Date
We respect your privacy. We protect your information.

PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

In an effort to respond to the privacy concerns of Canadians, the federal government enacted the Personal Information Protection and Electronic Documents Act (PIPEDA). Effective January 1, 2004, PIPEDA establishes principles for the collection, use and disclosure of personal information in Canada. Wilk & Wilk Orthodontics supports PIPEDA and the provincial privacy laws. We understand the importance of protecting your personal information and are committed to collecting, using and disclosing your personal information responsibly. As a result, Wilk & Wilk Orthodontics has implemented a Privacy Code, which may be reviewed at any time, and a Privacy Information Officer: Dr. Brian E. Wilk.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us and are all trained in the appropriate uses and protection of your information.

If you have any questions about how your privacy is protected in our office, please feel free to ask.

How Our Office Collects, Uses and Discloses Patients’ Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.

This office will collect, use and disclose information about you for the following purposes:

• to deliver safe, efficient and high quality patient care
• to assess your health needs and risks
• to advise you of treatment options
• to enable us to contact you and maintain communication with you
• to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
• to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
• to allow us to efficiently follow-up for treatment, care and billing
• for teaching and demonstrating purposes on an anonymous basis
• to complete and submit dental claims for third party adjudication and payment
• to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
• to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
• to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
• to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability
• to prepare materials for the Health Professions Appeal and Review Board (HPARB)
• to invoice for goods and services, process credit card payments and to collect unpaid accounts
• to assist this office to comply with all regulatory requirements
• to comply generally with the law

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

Patient Consent

I have reviewed the above information that explains how Wilk & Wilk Orthodontics will use my personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code that I can ask to see at any time, as well as a Privacy Information Officer.

I agree that your office can collect, use and disclose personal information about the below patient as set out above in the information about the office’s privacy policies. I am also aware that if a new purpose arises for the use and/or disclosure of my child’s personal information, your office will seek my approval in advance.
Patient Name*

First NameLast Name
Consent Signed by*

First NameLast Name
Relation to Patient*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: