Health History
Tell Us About Your Child
Todays Date
/
Month
/
Day
Year
Date
Nickname
Child's Name
First Name
Last Name
Email
example@example.com
SSN
Birthdate
-
Month
-
Day
Year
Date
Age
Sex
Please Select
Male
Female
School
Grade
Hobbies/Sports
Child's Home Number
Please enter a valid phone number.
Child's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is Accompanying Your Child Today?
Name
Relation
Do you have legal custody of this child?
Yes
No
Whom may we Thank for referring you?
List brothers/ sisters with ages:
General Dentist
Last Visit Date
Parent's Marital Status
Single
Partnered
Divorced
Married
Separated
Widowed
Mother's Information
Step Mother
Guardian
Email
example@example.com
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Work Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Employer
How long at current job
Mother's Information
Step Mother
Guardian
Email
example@example.com
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Work Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Employer
How long at current job
Job Title
Social Security #
Driver's License #
Father's Information
Step Father
Guardian
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Work Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Employer
How long at current job
Job Title
Social Security #
Driver's License #
Personal Responsible For Account
Name
First Name
Last Name
Relation
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Driver's License #
Employer
Work Number
Please enter a valid phone number.
SSN
Insurance Co Name
Who is responsible for making appointments
Name
Work Number
Please enter a valid phone number.
Primary Orthodontic Insurance
Orthodontic Coverage
Yes
No
Insurance Company Name
Insurance Company Address
Insurance Company Number
Please enter a valid phone number.
Group # (Plan Local or Policy #)
Policy Owners Name
Relationship to Patient
Policy Owner's Birthdate
-
Month
-
Day
Year
Date
ID #
Policy Owners Employer
Employers Address
Secondary Orthodontic Insurance
Orthodontic Coverage
Yes
No
Insurance Company Name
Insurance Company Address
Insurance Company Number
Please enter a valid phone number.
Group # (Plan Local or Policy #)
Policy Owners Name
Relationship to Patient
Policy Owner's Birthdate
-
Month
-
Day
Year
Date
ID #
Policy Owners Employer
Employers Address
What are the main concerns that you would like orthodontic treatment to accomplish?
Has your child ever taken Phen-Fen? (Also known as Redux or Pondimin)
Yes
No
If yes when
Has your child ever been evaluated or had orthodontic treatment before?
Yes
No
Have there been any injuries ot the face, mouth, teeth or chin?
Yes
No
List any musical instruments played:
Have adenoids or tonsils been removed?
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
Has your child been informed of any missing or extra permanent teeth?
Yes
No
Has your child ever had any pain/ tenderness in his/her jaw joint: (TMJ/TMD)?
Yes
No
Does your child brush his/her teeth daily?
Yes
No
Floss his / her teeth daily?
Yes
No
Is your child currently under the care of a physician?
Yes
No
Child's Physician
Phone Number
Please enter a valid phone number.
Date of Last Visit
Has puberty begun?
Yes
No
Has menstruation begun? (Girls)
Yes
No
Please describe your child's current physical health:
Please Select
Good
Fair
Poor
Please list all drugs that your child is currently taking:
Please list all drugs / things that your child is allergic to:
Any Hospital stays? Please explain:
Is your child allergic to
Latex
Metals/Nickel
Plastics
Has your child ever had any of the following medical problems?
Rows
Yes
No
Abnormal Bleeding
ADD /ADHD
Allergies to any Drugs
Allergic to Latex / Metals
Allergic to Plastic
Any Hospital Stays
Any Operations
Artificial Bones/Joints/Valves
Asthma
Cancer
Congenital Heart Defect
Convulsions / Epilepsy
Diabetes
Handicaps / Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV+ /AIDS
Kidney / Liver Problems
Lupus
Rheumatic /Scarlet Fever
Tuberculosis ( TB)
Mitral Valve Prolapse
Please discuss any medical problems that your child has had:
Has your child ever experienced any of the following?
Rows
Yes
No
Clenching / Grinding Teeth
Lip Sucking/Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb /Finger Sucking
Tongue Thrust
I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical or dental status at every appointment. I authorize the dental staff to perform the necessary dental services my child may need.
Date
/
Month
/
Day
Year
Date
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 deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office.
Date
/
Month
/
Day
Year
Date
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