Medical History Form for Kids

Medical Dental History Form for Patients Under Age 18
PATIENT
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First nameMiddle initialPatient's Last name
Prefers to be called
Hobbies, activities
Birth date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Social Security
School
Grade
E-mail address(es)
example@example.com
Address

Home address

Street Address Line 2

City, State, Zip codeState / Province

Postal / Zip Code
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
PARENT/GUARDIAN
Custodial parent(s) name(s)
Patient lives with (check all that apply)

Other
Patient lives with (check all that apply)

Other
Father's full name
Father's full name

Other
Occupation
E-mail address
example@example.com
Address (if different)
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Work phone

Area CodePhone Number
Mother's full name
Title

Other
Occupation
E-mail address
example@example.com
Address (if different)
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Work phone

Area CodePhone Number
DENTIST
Patient’s Dentist
Address, City, State
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen:
Name
City, State
Reason
PHYSICIAN
Patient’s Physician
City, State
Last seen
Reason
Next appointment
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
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?
Brother/sister name
Age
had orthodontic treatment?
If yes, where?
Brother/sister name
Age
had orthodontic treatment?
If yes, where?
Brother/sister name
Age
had orthodontic treatment?
If yes, where?
Brother/sister name
Age
had orthodontic treatment?
If yes, where?
Have any other family members been treated in this office? Please name them.
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address

Address (if different from page 1)

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
E-mail address(es)
example@example.com
Social Security
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
DENTAL INSURANCE
Primary policy holder’s full name
Birth date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security
Relationship to patient
Address and phone (if not listed above)

Area CodePhone Number
Employer
Address
Insurance company
Group
ID
Does this policy have orthodontic benefits?
Secondary policy holder’s full name
Birth date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security
Relationship to patient
Address and phone (if not listed above)

Area CodePhone Number
Employer
Address
Insurance company
Group
ID
Does this policy have orthodontic benefits?
MEDICAL INSURANCE
Policy holder’s full name
Insurance company
MEDICAL HISTORY

Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation.
Now or in the past, has your child had:

For the following questions mark yes, no, or don't know/understand (dk/u)
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any 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?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Does your child eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
DENTAL HISTORY

Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation.
Now or in the past has your child had:

For the following questions mark yes, no, or don't know/understand (dk/u)
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?
Chipped or injured primary or permanent teeth?
Any sensitive or sore 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?
History of speech problems?
Frequent oral habits sucking finger, chewing pen, etc?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in 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?
Has your child ever been diagnosed with gum disease or pyorrhea?
Has your child had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Metals (jewelry, clothing snaps)
Acrylics
Plant pollen
Animals
Foods
Other substances

Other
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.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Does the patient currently have (or ever had) a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child’s face or jaws?
Any other physical problems?
How often does your child brush?
How often does your child floss?
FAMILY MEDICAL HISTORY
Have the parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
RELEASE AND WAIVER

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
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 or omissions 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.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Medical Dental History Form for Patients Under Age 18

PATIENT

PARENT/GUARDIAN

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

Now or in the past, has your child had:

DENTAL HISTORY

Now or in the past has your child had:

Has your child had allergies or reactions to any of the following?

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

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 or omissions 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.