• Medical Dental History Form for Patients Under 18

    CONFIDENTIAL

  • PATIENT

  • Date*
     - -
  • Birth date*
     - -
  • What sex were you assigned on your birth certificate?*
  • What is your current gender identification?
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PARENT/ GUARDIAN

  • Patient lives with (check all that apply)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTIST

  • GENERAL INFORMATION

  • Have any other family members been treated in this office?
  • Rows

  • FINANCIAL RESPONSIBILITY

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTAL INSURANCE

  • Does the Patient have dental insurance?
  • Birth date
     - -
  • Does this policy have orthodontic benefits?
  • Birth date
     - -
  • Does this policy have orthodontic benefits?

  • MEDICAL INSURANCE

  • PHYSICIAN

  • 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).

  • MEDICAL HISTORY

  • Rows
  • Rows

  • DENTAL HISTORY

  • Rows
  • Frequent habit of thumb/ finger sucking?*
  • Current*
  • Frequent habit of tongue thrust?*
  • Current*
  • Frequent habit of fingernail biting?*
  • Current*
  • Frequent habit of lip sucking?*
  • Current*

  • PATIENT HEALTH INFORMATION

  • Does the patient take antibiotic pre-medication before any dental procedures?*
  • Do you think that any of your child's activities affect his/her/their face, teeth or jaws?*
  • Does your child chew or smoke tobacco?*
  • Have you noticed any unusual changes in your child's face or jaws?*

  • FAMILY MEDICAL HISTORY

  • Have your parents or siblings ever had any of the following health problems?*
  • Rows

  • RELEASE AND WAIVER

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

  • 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.

  • Date*
     - -
  • Should be Empty: