Adolescent Health History
Stephen C. Degenhardt, D.D.S., M.S.
Today's Date:
-
Month
-
Day
Year
Date
Date of birth:
-
Month
-
Day
Year
Date
Age:
Sex:
Male
Female
Name:
First Name
Middle Name
Last Name
Nickname:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone (if applicable):
Please enter a valid phone number.
Format: (000) 000-0000.
Home
Cell
Work
Family Dentist:
City:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Family Physician:
City:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
School:
City:
Grade:
Please enter a valid phone number.
Format: (000) 000-0000.
Sports/Hobbies, etc:
Responsible Party Information
Name of person responsible for Patient account:
First Name
Last Name
Relationship:
Parents:
Married
Separated
Divorced
Father Deceased
Mother Deceased
Child lives with:
Both parents
Mother
Father
Other/whom:
Father's Name:
First Name
Last Name
Employer:
Occupation:
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Father's Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Cell Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Name
First Name
Last Name
Employer:
Occupation:
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Mother's Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Cell Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
General Health:
Good
Fair
Poor
Height
Weight (lbs)
Presently under medical care for:
Birth defects:
Drugs or medication being taken now (drug and dose):
Allergic to (medication, metal, latex, etc.):
Please check yes or no to the following and date:
Adopted child:
Yes
No
Year
Adenoids (removed):
Yes
No
Year
Allergies:
Yes
No
Year
Blood/bleeding problems:
Yes
No
Year
Bone disorder:
Yes
No
Year
Diabetes:
Yes
No
Year
Ear/Nose infections:
Yes
No
Year
Emotional:
Yes
No
Year
Endocrine disorder:
Yes
No
Year
Epilepsy:
Yes
No
Year
Fainting spells:
Yes
No
Year
Glaucoma:
Yes
No
Year
Heart disorder/murmur:
Yes
No
Year
Hepatitis:
Yes
No
Year
Hospitalized:
Yes
No
Year
Hyperactivity:
Yes
No
Year
Learning disorder:
Yes
No
Year
Liver disorder:
Yes
No
Year
Lung disorder:
Yes
No
Year
Lung disorder:
Yes
No
Year
Rheumatic fever:
Yes
No
Year
Scoliosis:
Yes
No
Year
Sexually transmitted disease:
Yes
No
Year
Speech difficulty:
Yes
No
Year
Other:
Yes
No
Year
Do you require antibiotic premedication prior to dental appointments?
Yes
No
If yes, which antibiotics do you usually take?
Please give us any additional information or details where necessary:
Breathing/Airway History (please select all that apply):
Snoring
Teeth Grinding
Bed wetting
Adenoids & tonsil enlargement or removal
Restless sleep at night
ADHD symptoms: hyperactive, difficulty paying attention
Family History
Names and ages of brothers and sisters:
Other family members with similar dental conditions or orthodontic treatment (names and ages):
If so, have we treated any of these family members?
Yes
No
Have you had any other experience with or seen another orthodontist?
Yes
No
Name
Maturation
Have you grown very much in the past year?
Yes
No
How many inches?
Female patients: Monthly Periods?
Yes
No
Started at age:
Male patients: Voice change?
Yes
No
Facial Hair?
Yes
No
Other indications of pubertal development:
Dental History
Date of last dental check-up:
-
Month
-
Day
Year
Date
Injury of trauma to the face or teeth:
Does the patient play a musical instrument?
Thumb sucking?
Discontinued at the age of
Has the patient noticed or been diagnosed as having any of the following problems due to a poor bite?
Worn or sore teeth
Yes
No
Year
Loose teeth
Yes
No
Year
Bone and gum recession
Yes
No
Year
Headaches and/or jaw joint problems
Yes
No
Year
Speech difficulty
Yes
No
Year
Bruxism and/or clenching
Yes
No
Year
Patient's Treatment Attitude
Major reason for seeking treatment:
How did you become aware of the orthodontic problem?
Patient interest in treatment:
Patient wants treatment
Unwilling, but agrees
Treatment if necessary
Uncooperative
Questionnaire completed by:
First Name
Last Name
Relationship to patient:
How/when did you first hear about our office?
Whom may we thank for referring you to our office?
Comments/Concerns:
Submit
Should be Empty: