Medical History Under 18 2023

Date*

Date

Patient's Last name*

First name*

Prefers to be called

Hobbies, activities

Birth date*

Date

MaleFemale

MaleFemaleOther

What are the patient's preferred pronouns?

Home address*

City, State, Zip Code*

Cell phone*

Format: (000) 000-0000.

School

Grade

Custodial parent(s) name(s)*

Parent 1/GuardianParent 2/GuardianOther

Parent 1/Guardian full name*

Email address*

example@example.com

Address (if different)

Cell Phone (if different)

Format: (000) 000-0000.

Parent 2/Guardian full name

Email address

example@example.com

Address (if different)

Cell Phone (if different)

Format: (000) 000-0000.

Patient's Dentist

Address, City, State

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen

Name

City, State

Reason

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 your child might need orthodontic treatment?*

Why did you select our office?

Describe any previous orthodontic treatment or consultations.

Does your child play any musical instruments? If yes, what?*

Sibling name name age age

YesNo

If yes, where?

Sibling name name age age

YesNo

If yes, where?

Sibling name name age age

YesNo

If yes, where?

Have any other family members been treated in this office?

Please name them.

Who is financially responsible for this account*

Address (if different)

City, State, Zip

Cell phone*

Format: (000) 000-0000.

E mail address(es)*

example@example.com

Primary policy holder's full name

Birth date

Date

Relationship to patient

Employer

Group #

ID #

YesNo

Secondary policy holder's full name

Birth date

Date

Relationship to patient

Employer

Group #

ID #

YesNo

Does the patient currently have (or ever had) a substance abuse problem?*

Do you think any of your child's activities affect his/her face, teeth or jaws? How?*

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

Medication

Taken for

Medication

Taken for

Medication

Taken for

Does your child chew or smoke tobacco?*

Have you noticed any unusual changes in your child's face or jaw*

Any other physical problems

Now or in the past has your child had:

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

yesnodk/n

If yes, please explain

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

yesnodk/n

If yes, please list

Now or in the past, has the patient had:

yesnodk/n

yesno

Age Stopped

yesnodk/n

yesno

Age Stopped

yesnodk/n

yesno

Age Stopped

yesnodk/n

yesno

Age Stopped

yesnodk/n

How often does your child brush?*

How often does your child floss?*

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?

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

Parent/Guardian Signature*

Date*

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.

Parent/Guardian Signature*

Date*

Date

PATIENT

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

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

MEDICAL HISTORY

DENTAL HISTORY

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER