Medical Dental History Form for Patients Under Age 18

Medical Dental History Form

for Patients Under Age 18
Name

First NameMiddle NameLast Name
Prefers to be called
Hobbies, activities
Birthday

MonthDayYear
Date
Social Security Number
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Social Security Number
Patient lives with (check all that apply)

MotherFatherStepmotherStepfatherGrandparent(s)Other
Parent/Guardian
Mother/Guardian:

First NameMiddle NameLast Name
Birthday

MonthDayYear
Date
SSN
Address (if different than patient address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Employer
Phone Number
Please enter a valid phone number.
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance
Group Number
ID Number
Father/Guardian:

First NameMiddle NameLast Name
Birthday

MonthDayYear
Date
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance
Group Number
ID Number
Who is financially responsible for this account?
Who will be responsible for bringing the patient to orthodontic appointments?
Medical Insurance
Policy holder’s full name

First NameMiddle NameLast Name
Insurance Company
AS A COURTESY, WE WILL BILL YOUR INSURANCE FOR YOU. ANY REMAINING BALANCE WILL BE YOUR RESPONSIBILITY. DO YOU AUTHORIZE PAYMENT DIRECTLY TO DENTIST?

YesNo
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Date

MonthDayYear
Date
Dentist
Dentist Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Seen
Next Appointment
Reason
Other dentists/dental specialists now being seen:
Reason
General Information
What concerns you about your child’s teeth?
Who suggested that your child might need orthodontic treatment?
How does your child feel about orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultation?
Does your child play a musical instrument?
Have any other family members been treated in this office? Please name them.
Brother/sister name age had orthodontic treatment?

YesNo
If yes, where?
Brother/sister name age had orthodontic treatment?

YesNo
If yes, where?
Brother/sister name age had orthodontic treatment?

YesNo
If yes, where?

MEDICAL HISTORY Now or in the past, has your child had:

	Yes	No	Don't Know
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, STD?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problem?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorder (anorexia, bulimia)?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, swollen ankles?
Heart defects, heart murmur, rheumatic disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

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

	Yes	No	Don't Know
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Metals (jewelry, clothing snaps)
Acrylics
Plant pollens
Animals
Foods
Other substances

DENTAL HISTORY Now or in the past, has your child had:

	Yes	No	Don't Know
Permanent or extra teeth removed?
Extra or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
“Gum boils,” frequent canker or cold sores?
Speech problems or speech therapy?
Difficulty breathing through nose?
Food impaction between the teeth?
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?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associate with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?

PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take and what they are taken for.
Does the patient have or ever had a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any 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 your 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 orthodontic treatment to my dental and/or medical insurance company.
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MonthDayYear
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staffresponsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontistof any changes in my medical or dental health.
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MonthDayYear
Date
Patient Acknowledgement and Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgment, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our
professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading “acknowledgement” to acknowledge that you have today received a copy of our notice of privacy practices. I acknowledge that I have today received a copy of the Notice of Privacy Practices.
Parent/Guardian Signature

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List Patient Names
Date

MonthDayYear
Date
Patient Consent

Please sign this form below under the heading “consent” to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment. I understand that such
disclosures may not be of the type listed above.
Parent/Guardian Signature

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List Patient Names
Date

MonthDayYear
Date
Should be Empty:

Medical Dental History Form

Parent/Guardian

Medical Insurance

Dentist

General Information

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER