Under 18 Patient Form

Medical Dental History Form For Patients Under Age 18
Date

MonthDayYear
Date
Patient Name*

First NameLast Name
Prefers to Be Called*
Hobbies, Activities*
DOB*

MonthDayYear
Date
What sex were you assigned on your birth certificate?*
Social Security Number*
School*
Grade*
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone*
Please enter a valid phone number.
Parent/Guardian
Patient lives with (check all that apply)*

Parent 1/GuardianParent 2/GuardianParent 3/Guardian
Parent 1/Guardian Name*

First NameLast Name
Occupation*
Email*
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone (if different)*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
Parent 2/Guardian Name

First NameLast Name
Occupation
Email
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone (if different)
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Who will be responsible for picking up/dropping off the patient?*
Dentist
Patient's Dentist*
Last Seen*

MonthDayYear
Date
Reason(s)*
Next Appointment*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Dentist/Specialist(s) Being Seen*
Reason(s)*
General Information
What concerns you about your child's teeth?
What concerns your child about their teeth?
How does your child feel about orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultations:
Does your child play any musical instruments?
Please list any siblings of the patient, their age, and whether they have undergone orthodontic treatment:
Have any other family members been treated in this office? Please name them if so:
Financial Responsibility
Who is financially responsible for this account?*
Address (if different from the Patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Social Security Number*
Employer*
Dental Insurance
Primary Policy Holder's Full Name*

First NameMiddle NameLast Name
DOB*

MonthDayYear
Date
Social Security Number*
Relationship to Patient*
Address (if not listed above)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (if not listed above)*
Please enter a valid phone number.
Employer*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company*
Group #*
ID #*
Does this policy have orthodontic benefits?*

YesNoDon't Know
Secondary Policy Holder's Full Name

First NameMiddle NameLast Name
DOB

MonthDayYear
Date
Social Security Number
Relationship to Patient
Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (if not listed above)
Please enter a valid phone number.
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group #
ID #
Does this policy have orthodontic benefits?

YesNoDon't Know
Patient Health Information
Do you think that any of your child's activities affect their face, teeth or jaws? If so, how?*
List any medication, nutritional supplements, herbal medications, or non-prescription medicines, including fluoride supplements that your child takes.*
Have you noticed any unusual changes in your child’s face or jaws?*
Any other physical problems?*
Medical History

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).

Now or in the past, has your child had...*

	Yes	No	DK/U
Emotional, sensory, or developmental issues?
Heredity of developmental conditions?
Bone fractures, or major injuries?
Any injuries to the face, head, or neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
Cancer, tumor, radiation treatment, or chemotherapy?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Excessive bleeding or bruising, anemia?
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?
AIDS or HIV positive?
Hepatitis, jaundice, or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurological problems?
Mental health disturbances or depression?
Vision, hearing, or speech problems?
History of an eating disorder?
High or low blood pressure?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Has your child taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Has your child ever taken oral medication for bone disorders or cancer such as bisphosphonates such as Fosamax (alendronate), Skelid (tiludronate) Actonel (ridendronate), Boniva (ibandronate), or Didronal (etidronate)?

Have you had any allergies or reactions to any of the following:*

	Yes	No	DK/U
Local anesthetics (novocaine, lidocaine)
Latex (balloons, gloves)
Aspirin
Ibuprofen
Penicillin
Other Antibiotics
Metals (jewelry, clothing snaps)
Acrylics
Plant Pollens
Animals
Foods
Other Subtances

If Other Substances, please list:
Dental History

Now or in the past, has your child had...*

	Yes	No	DK/U
Chipped or injured primary/permanent teeth?
Bleeding gums, bad taste, or mouth odor?
Primary (baby) teeth removed that were not loose?
Supernumerary (extra) or congenitally missing teeth?
Permanent or extra teeth removed?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
"Gum boils," frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Frequent headaches or migraines?
Any sensitive or sore teeth?
Food impaction between the teeth?
Frequent oral habits (sucking fingers, 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 chewing, or opening jaw?
Does your child frequently breath through their mouth?
Have you ever been treated for TMJ/TMD problems?
Any serious trouble associated 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?

How often does your child brush their teeth?*
How often does your child floss their teeth?*
Release & Waiver
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance.
Signature*

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Date

MonthDayYear
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of their 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.
Signature*

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Date

MonthDayYear
Date

Patient Consent Form

L. Douglas Knight, DMD, ABO
I understand, that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

- Obtain payment from third-party payers.

- Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
Patient Name*

First NameLast Name
Date

MonthDayYear
Date
Parent/Guardian Signature*

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Should be Empty:

	Yes	No	Don't Know
Snore more than half the time?
Always snore?
Snore loudly?
Have heavy or loud breathing?
Have trouble breathing/struggle to breathe?

	Yes	No	Don't Know
Tend to breathe through their mouth while awake?
Have a dry mouth upon waking in the morning?
Occasionally wet the bed?
Wake up feeling un-refreshed in the morning?
Have a problem with sleepiness during the day?
Has a teacher or supervisor commented that your child appears to sleep during the day?
Is it hard to wake your child in the morning?
Does your child wake up with headaches?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?

	Yes	No	Don't Know
Does not seem to listen when spoken to directly.
Has difficulty organizing tasks.
Is easily distracted by extraneous stimuli.
Fidgets with hands/feet or squirms in seat.
Is always "on the go" or often acts as if "driven by a motor."
Frequently interrupts or intrudes on others (e.g., butts into conversations or games).

Medical Dental History Form For Patients Under Age 18

Parent/Guardian

Dentist

General Information

Financial Responsibility

Dental Insurance

Patient Health Information

Medical History

Dental History

Release & Waiver

Quality of Life Survey

Sleep Disturbances

Physical Suffering

Emotional Distress

Daytime Problems

Caregiver Concerns

Pediatric Sleep Questionnaire

Patient Consent Form