Medical History Under 18 2023

  • PATIENT

    Confidential
  • Date*
     / /
  • Birth date*
     / /
  • What sex was the patient assigned on their birth certificate?*
  • What is the patient's current gender identification?*
  • Format: (000) 000-0000.

  • PARENT/GUARDIAN

  • Patient lives with (check all that apply) Other, if other, what is the relationship?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTIST

  • Other dentists/dental specialists now being seen 

  • GENERAL INFORMATION

  • Sibling name age   

  • Had Orthodontic Treatment?

  • Sibling name age   

  • Had Orthodontic Treatment?

  • Sibling name age   

  • Had Orthodontic Treatment?

  • Have any other family members been treated in this office? 

  • FINANCIAL RESPONSIBILITY

  • Format: (000) 000-0000.

  • DENTAL INSURANCE

    Leave this section blank if you do NOT have orthodontic coverage!
  • Birth date
     / /
  • Does this policy have orthodontic benefits?
  • Birth date
     / /
  • Does this policy have orthodontic benefits?

  • Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, mark yes, no, or don't know/understand dk/u.

  • PATIENT HEALTH INFORMATION

  • Does the patient take antibiotic pre-medication before any dental procedures?*

  • List any medications, nutritional supplements, herbal medications or non-prescription medicines, fluoride supplements your child takes.

  • MEDICAL HISTORY

  • Now or in the past has your child had:  

  • Emotional, sensory or developmental issues?*
  • Hereditary or developmental conditions?*
  • Bone Fractures or major injuries?*
  • Any injuries to face, head or 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 disease?*
  • AIDS or HIV positive?*
  • Hepatitis, jaundice or other liver problems?*
  • Polio, mononucleosis, tuberculosis, pneumonia?*
  • Seizures, fainting spells, neurologic problems?*
  • Mental health disturbance or depression?*
  • History of eating disorders (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 adenoids removed?*
  • Does your child frequently breathe through his/her mouth?*
  • Has your child ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?*
  • Has your child ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (Etidronate)?*

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

  • Latex (gloves, ballons)?*
  • Metals (jewelry, clothing snaps)?*
  • Acrylics?*
  • Local anesthetics (novocaine, lidocaine, xylocaine)*
  • Aspirin*
  • Ibuprofen (Motrin, Advil)*
  • Penicillin*
  • Other antibiotics*
  • Plant pollens*
  • Animals*
  • Foods*

  • DENTAL HISTORY

  • Now or in the past, has the patient had:

  • Erupting teeth very early or very late?*
  • Primary (baby)teeth removed that were not loose?*
  • Permanent or extra teeth removed?*
  • Supernumerary (extra) or congenitally missing teeth?*
  • Chipped or injured primary or permanent 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?*
  • Frequent habit of thumb sucking/finger sucking?*
  • Current*
  • Frequent habit of tongue thrust?*
  • Current*
  • Frequent habit of fingernail biting?*
  • Current*
  • Frequent habit of lip sucking?*
  • Current*
  • Teeth causing irritation to lip, cheek or gums?*
  • Teeth grinding or clenching?*
  • Clicking or locking in jaw joints?*
  • Soreness in jaw muscles or face muscles?*
  • Has your child been treated for "TMJ" or "TMD"?*
  • Any broken or missing fillings?*
  • Any serious trouble associated with previous dental treatment?*
  • Has your child ever been diagnosed with gum disease or pyorrhea?*

  • FAMILY MEDICAL HISTORY

  • Have the parents or siblings ever had any of the following health problems? If so, please explain.

  • RELEASE AND WAIVER

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

  • Date*
     / /

  • 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*
     / /
  •  
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