Henry Advanced Orthodontics - Child Health History Form

Child Patient Health Record
Date

MonthDayYear
Date
Nickname
Name

First NameLast Name
Select One

MalesFemale
Date of Birth

MonthDayYear
Date
Age
Height
Weight
School
Grade
Home Phone
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information

Who is Accompanying the Child Today?
Name

First NameLast Name
Relation
Do you have Legal Custody of this Child?

YesNo
Other Siblings
General Dentist: Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Last Date Visited

MonthDayYear
Date
Name (Emergency Contact)

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is Responsible for Account?
Parent Marital Status

SingleMarriedPartneredWidowedDivorcedSeparated
Father
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address (if different than Child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Please enter a valid phone number.
Cell/Other
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext.
Employer
Occupation
If you have Orthodontic Insurance Coverage for the child, please fill out below:
Insurance Company Name
Group # (Plan, Local or Policy)
ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address (if different than Child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Please enter a valid phone number.
Cell/Other
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext.
Employer
Occupation
If you have Orthodontic Insurance Coverage for the Child, please fill out below:
Insurance Company Name
Group # (Plan, Local or Policy)
ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I herby authorize the release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature of parent or guardian

Clear
Date

MonthDayYear
Date
What is Your Primary Concern
Dental History

Now or in the past, has the patient had:

	Yes	No	dk/u
Started Teething Very Early or Very Late?
Permanent or "Extra" (Supernumerary) Teeth Removed?
Chipped or Injured Primary (Baby) / Permanent Teeth?
Jaw Fractures, Cysts or Mouth Infections?
Thumb, Finger or Sucking Habit? Until What Age?
Abnormal Swallowing Habit (Tongue Thrusting)?
Difficulty Encountered in Chewing or Jaw Opening?
Concerned About Spaced, Crooked or Protruding Teeth?
"Gum Boils", Frequent Canker Sores or Cold Sores?
Taking any Forms of Fluoride?
Any Relative with Similar Tooth of Jaw Relationships?
Ever Had a Prior Orthodontics Examination or Treatment?

I understand that the information I have given is correct to the best of my knowledge, that it will be help in the strictest confidence and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental/orthodontic services my child may need.
Signature of parent or guardian

Clear
Date

MonthDayYear
Date
Patient Profile
For the following questions mark Yes, No or Don't Know/Understand (dk/u). The answers are for the office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Has the patient had:

	Yes	No	dk/u
Does Patient Follow Directions Well?
Does Patient Have Learning Disabilities?
Does Patient Brush His/Her Teeth Conscientiously?
Is Patient Sensitive or Self-Conscious About Teeth?

Medical History

Now of in the past, has the patient had:

	Yes	No	dk/u
AIDS, ARC, HIV Positive or Other STD
Allergies or Hives - Hay Fever, Asthma, Sinus Trouble
Anemia, Excessive Bleeding or Bruising Tendency
Anorexia or Bulimia
Arthritis or Rheumatoid Conditions
Asthma
Birth Defects or Hereditary Problems
Bleeding Disorders or Taking Blood Thinners
Bone Fractures or Any Major Accidents
Cancer or Tumor/Chemo/Radiation Treatments
Cankers or Cold Sores (Mouth or Body)
Diabetes (Adult or Juvenile Onset)
Epilepsy, Seizures or Convulsions
Eye, Ear, Nose or Throat Condition
Fainting or Dizzy Spells
Frequent Headaches, Colds or Sore Throat

Now of in the past, have you had:

	Yes	No	dk/u
Handicapped or Disabled
Heart Problem (Heart Defect, Murmur)
Hepatitis (A, B or C) Jaundice or Other Liver Disorder
Herpes
High or Low Blood Pressure
Immune System Conditions
Kidney Disease
Mental Health, Behavioral Problems or Depression
Sickle Cell Anemia
Tonsil or Adenoid Conditions
Tuberculosis (TB)
Ulcers (Stomach, Intestine, Mouth)
Vision, Hearing, Tasting or Speech Difficulties

Are there any other Medical Conditions that We should be Aware of?

Allergies or Reactions to any of the following:

	Yes	No	dk/u
Local Anesthetics (Novocaine or Lidocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin or Other Antibiotics
Sulfa Drugs
Codeine or Other Narcotics
Metals (Jewelry, Clothing Snaps)
Acrylic
Latex (Gloves, Balloons)
Vinyl
Is the patient taking Medications, Nutritional Supplements, Herbal medications or Non-Prescription Medicines? Please list below

Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Does the patient Have or ever had a Substance Abuse Problem?

YesNodk/u
Does the patient chew or Smoke Tobacco?

YesNodk/u
Operations?

YesNodk/u
Describe:
Hospitalized?

YesNodk/u
For:
Other Physical Problems or Symptoms?

YesNodk/u
Describe:
Being Treated by Another Health Care Professional?

YesNodk/u
For:
Date of Most Recent Physical Exam:

MonthDayYear
Date

Females Only:

	Yes	No	dk/u
Are you taking Birth Control?
Is the Patient Pregnant?
Is the patient Nursing?

Has the patient started menstruation?

YesNodk/u
If so, approximately when?
Family Medical History

Do the Patient's Parents or Siblings Have Any of the Following Health Problems? If so, Please Explain:

	Yes	No	dk/u
Bleeding Disorders
Diabetes
Arthritis
Metabolic Disturbances
Severe Allergies
Unusual Dental Problems
Jaw Size Imbalance

Another Other Medical Conditions That We Should Know About?

YesNodk/u
Describe
What other disease, condition, or problem does your child have that is not previously listed?
I certify that the above information is correct to the best of my knowledge. I understand I must notify Dr. Chris Henry and/or her staff immediately at any time my information changes.
Signature

Clear
Date

MonthDayYear
Date
I authorize the release of medical/dental information to any of the following if needed: My child's physician, any other physician or other dental offices he/she may be referred to, attorneys (with my prior release by signature), and my insurance company.
Signature

Clear
Date

MonthDayYear
Date
I understand Dr. Chris Henry may photograph my child's face and mouth for the purpose of documentation in his/her record. blanks (initial). I further understand and grant my permission to Dr. Chris Henry to use my child's photographs for educating other patients, prospective patients or other health care professionals, which may include but not be limited to, inclusion on Dr. Chris Henry's website, office photographs or video.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Child Patient Health Record

Parent Information

Father

Mother

Dental History

Patient Profile

Medical History

Family Medical History