Stewart Family Orthodontics Health History

CHILD PATIENT HEALTH HISTORY INFORMATION
Patient's Name*

First NameLast Name
Preferred Name*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address (Responsible Party)*
example@example.com
Patient Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Other family members seen by us
School
Hobbies
Who referred you to our office?
Names and ages of siblings?
Name of General Dentist

First NameLast Name
Date of Last Exam

MonthDayYear
Date
Responsible Party Information
Primary Responsible Party
Name*

First NameLast Name
Relationship To Patient*
Mobile Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email address*
Secondary Responsible Party
Name

First NameLast Name
Relationship To Patient
Mobile Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email address
Marital status

SingleMarriedDivorcedWidowed
Patient Lives With

MotherFatherBothOther
Is patient adopted?

YesNo
Insurance Information
Does your child have dental insurance?*

YesNo
If yes, then please complete the following:
Primary Coverage
Policy Holder's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Employer*
Social Security Number*
Insurance Carrier*
Group #*
Policy #*
Carrier's Phone # (if you'd like us to check on your behalf)
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Coverage
Does your child have secondary dental insurance?

YesNo
If yes, please complete the following:
Policy Holder's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Employer*
Social Security Number*
Insurance Carrier*
Group #*
Policy #*
Carrier Phone # (if you'd like us to check on your behalf)
Please enter a valid phone number.Format: (000) 000-0000.
Medical History

The following information is required to enable us to provide your child with the best possible care. All information is strictly private and is protected by doctor-patient confidentiality. The orthodontist will review your medical history and explain any questions that you do not understand.
Is your child being treated for any medical condition at this time or has s/he been treated for a medical condition within the past two years?*

YesNo
If yes, please explain:
Has there been a change in your child's health within the past two years?*

YesNo
If yes, please explain:
Is your child currently taking any medications, non-prescription drugs, or herbal supplements?*

YesNo
If yes, please explain:
Does your child have any allergies? If yes, please explain using the categories below:*

YesNo
a) Medications
b) Latex and/or rubber products
c) Other (e.g. foods, hayfever, etc.)
Has your child had his/her adenoids and/or tonsils removed?*

YesNo
Does your child have any conditions or therapies that could affect their immune system (e.g. leukemia, AIDS, HIV, radiotherapy, chemotherapy)?*

YesNo
Has your child ever been hospitalized for any illnesses or operations?*

YesNo
If yes, please explain:
Has your child ever been treated by a physician for (check all that apply):
Does your child have any other medical conditions?*

YesNo
If yes, please explain:
Is your child in good health?*

YesNo
Dental History
What concerns do you have about your child's teeth/smile?*
Is your child nervous during dental treatment?*

YesNo
Is your child a mouth-breather while sleeping or awake (or both)?*

YesNo
Has your child ever had a habit such as thumb or finger sucking, nail biting, lip sucking, grinding teeth, or an unusual swallow pattern?*

YesNo
Have you ever been informed that your child has any missing or extra permanent teeth?*

YesNo
Have there been any injuries to your child's face, mouth, or teeth?*

YesNo
Has your child experienced any jaw joint noises, pain, or limited movement?*

YesNo
Have you previously consulted an orthodontist?*

YesNo
Has any member of your family had orthodontic treatment?*

YesNo
Did any family member's orthodontic treatment include jaw surgery or tooth extractions?

YesNo
Has your child ever experienced any complications following dental treatment?*

YesNo
Is your child currently having any dental treatment or had a filling in the past year?*

YesNo
Is your child being teased at school because of his/her teeth ?*

YesNo
Has your child ever had instructions in proper brushing technique?*

YesNo
Do your child's gums bleed when brushed?*

YesNo
Does your child have any other dental problems?*

YesNo
If yes, please explain:
Patient Consent

Privacy of your personal health information is an important part of our office's providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. In this office, Dr. Daniel Stewart is the contact person for personal health information related matters. All staff members who come into contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
- Only necessary information is collected about you.
- We only share your information with your consent.
- Storage, retention and destruction of your personal health information complies with existing legislation, and privacy protection protocols.
- Our privacy protocols comply with ADA standards.
Do not hesitate to discuss our policies with Dr. Stewart or any member of our office staff. By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance.
AUTHORIZATION
To the best of my knowledge, the above information is correct. If there is a change in my health history, or my medications change, I will inform the orthodontist at the next appointment.*

Agree
When appropriate or necessary, the orthodontist may send and discuss my health information with other involved health professionals.*

Agree
Form Submission Date*

MonthDayYear
Date
Signature*
Additional Comments/Notes
Should be Empty:

CHILD PATIENT HEALTH HISTORY INFORMATION

Responsible Party Information

Primary Responsible Party

Secondary Responsible Party

Insurance Information

If yes, then please complete the following:

Primary Coverage

Secondary Coverage

If yes, please complete the following:

Medical History

Dental History

Patient Consent

AUTHORIZATION