Child Health History Form

Child Health History Form
Patient Information
Name

First NameLast Name
Preferred Name (if different than above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
D.O.B.

MonthDayYear
Date
Sex
Dentist
Family Physician
Emergency Contact
Relationship to You
Phone Number
Please enter a valid phone number.
If Applicable
Status Card #
Is your child covered under the Supplementary Health or Family Health Benefits Program (eligibility determined by the Ministry of Social Services)?

YesNo
If "Yes," please provide Provincial Health Card #
Parent/Guardian Information
Parent/Guardian's Name(s)
Parent(s) is/are ...
If different than above
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Parent's Email (for appointment reminders)
example@example.com
How did you hear about our clinic?
Do you have private insurance that covers orthodontics?

YesNo
We will provide you with an estimate and receipt at the end of your appointment, and you can submit this information for reimbursement.
If yes, how many plans?
Medical History

Have you ever had any of the following? Please check the YES or NO boxes to answer: (All answers are confidential)*

	Yes	No
Is your child in good health?
Currently under the care of a physician for a specific concern?
Allergies or drug reactions (including latex and penicillin)?
Ever taken bisphosphonate medications to treat bone loss (Alendronate/Fosamax, Etidronate/Didrocal®, Risedronate/Actonel®, Zoledronic acid/Aclasta®)?
Taking any medications?
Birth defects or hereditary problems?
Operations?
Bone fractures or major accidents?
Rheumatoid or arthritic conditions?
Osteoporosis?
Kidney Problems?
Diabetes?
Cancer or have been treated for a tumor?
Polio, mononucleosis, tuberculosis, pneumonia?
Problems with your immune system?
AIDS or HIV?
Hepatitis, jaundice, or liver problems?
Fainting spells, seizures, epilepsy or neurologic disease?
Mental health, behavioral or concentration problems?
Vision, hearing, tasting or speech difficulties?
Loss of weight recently or poor appetite?
Excessive bleeding, bruise easily, anemia or bleeding disorder?
High or low blood pressure?
Tires easily?
Chest pain, shortness of breath or swollen ankles?
Cardiovascular problems (heart trouble, heart attach, angina, coronary insufficiency, arteriosclerosis, stroke, heart murmur, or congenital heart defects)?
Previous history of Infective Endocarditis?
Prosthetic joint replacement?
Been told to take prophylactic antibiotics prior to dental procedures?
Frequent headaches?
Hay fever, asthma, sinus trouble, hives?
Had tonsils/adenoids removed?
Smoke, use tobacco or any recreational drugs?
Reached puberty (Girls - started menstruating, Boys - voice changed)?

Females Only*

	Yes	No
Currently taking birth control?
Pregnant or nursing?

If you answered yes, to any of the medical history questions, please provide an explanation for your answer:
Dental History

	Yes	No
Regular dental checkups?
Recent dental cleaning?
Have cavities needing to be fixed?
Previous trauma to teeth?
Teeth sensitive to hot/cold or ache?
Jaw fractures, cysts, or pathology?
Gum disease (bleeding gums)?
Frequent canker sores or cold sores?
Thumb, finger or sucking habit?
Speech problems?
Chronic mouth breathing, snoring or difficulties in breathing?
Tooth grinding, clenching, clicking or locking?
Pain in jaw joints or ringing in ears?
Difficulties chewing or opening jaw?
Had previous orthodontic examination or treatment?

I have read and understand the above questions. 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.

If there are any changes later to this history record or medical/dental status, I will inform this practice.
Initial
Signature of Parent/Guardian

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Child Health History Form

Patient Information

Parent/Guardian Information

Medical History

Dental History