Frederick S. Fritz Child Health History

Frederick S. Fritz Child Health History

We would like to welcome you and your child to our office! In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Please give us a call if you have any questions. Thank you!
Patient Information
Patient Name: *
Preferred Pronoun:*

HeSheNon-binary/they
Gender:*
SSN:
Birth Date:*

MonthDayYear
Date
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
School:
Grade:
Please list any sports or extracurricular activities:
Siblings:
Parent/Guardian Information
Name:*

First NameLast Name
Relationship to Patient:*
Marital Status:*
SSN:
Driver's License Number
Birth Date:*

MonthDayYear
Date
Primary Phone: *
Please enter a valid phone number.
Secondary Phone:
Please enter a valid phone number.
Employer: *
Occupation:*
Check this box if your address is the same as the patient's address. Otherwise, please fill in your address below.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name:

First NameLast Name
Relationship to Patient:
Marital Status:
SSN:
Driver's License Number
Birth Date:

MonthDayYear
Date
Primary Phone:
Please enter a valid phone number.
Secondary Phone:
Please enter a valid phone number.
Employer:
Occupation:
Check this box if your address is the same as the patient's address. Otherwise, please fill in your address below.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any other people to whom it is okay to release appointment and medical information.
Emergency Contact

Please provide an emergency contact outside the home, in the event parents cannot be reached.
Name*

First NameLast Name
Primary Phone Number: *
Please enter a valid phone number.
Relationship to Patient: *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance Information
If you do not have dental insurance, please check this box and skip this section.

I do not have dental insurance.
Primary Dental Insurance Company
Phone Number
Please enter a valid phone number.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relationship to Patient
Policy Holder's SSN
Policy Holder's SSN
Policy Holder's Birth Date

MonthDayYear
Date
Employer
Work Phone
Please enter a valid phone number.
Co-pay
Deductible
Primary Dental Insurance Company
Phone Number
Please enter a valid phone number.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relationship to Patient
Policy Holder's SSN
Policy Holder's SSN
Policy Holder's Birth Date

MonthDayYear
Date
Employer
Work Phone
Please enter a valid phone number.
Co-pay
Deductible
Health History
General Dentist
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Last Visit
Date of Last Visit

MonthDayYear
Date
How did you hear about us?

AdInternetFamily or friend referralPhysician of dentist referralOther
Name of referring person
Have we treated other family members?

YesNo
Details:
What are the main concerns you'd like orthodontics to address?
Has your child visited an orthodontist before?*

YesNo
Have your child's tonsils or adenoids been removed?*

YesNo
Has your child ever experienced jaw joint pain or discomfort (TMJ/TMD)?*

YesNo
Does your child have any missing or extra permanent teeth?*

YesNo
Does your child have speech problems?*

YesNo
Does your child like their smile?*

YesNo
Does your child smoke?*

YesNo
Do your child's gums bleed?*

YesNo
Has your child ever had an injury to any of the following?*

TeethMouthChinNone of the above.
Does your child currently or has your child ever had any of the following habits?*

Clenching or grinding teethMouth breathingThumb or finger suckingLip sucking or bitingNail bitingProlonged pacifier useTongue thrustingNone of the above.
Physician: *
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for last visit: *
Date of last visit: *

MonthDayYear
Date
Does your child have any allergies or sensitivities to medications or latex?

YesNo
Is your child currently taking any medications?

YesNo
Has puberty or menstruation begun?

YesNo
Is your child pregnant?

YesNo
Please describe any medical conditions that are currently being treated.
Has your child had any serious illnesses or operations?

YesNo
Details:
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

YesNo
Check if your child has or has ever had any of the following:

AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal DiseaseNone of the Above
Authorization
I affirm that the information given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical information.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Signature*

Powered by Jotform Sign Clear
Date*

MonthDayYear
Date
Should be Empty:

Frederick S. Fritz Child Health History

Patient Information

Parent/Guardian Information

Emergency Contact

Dental Insurance Information

Health History

Authorization