Existing Patient Update Form

Existing Patient Update Form - Child
Patient Information
Date

MonthDayYear
Date
Patient's Full Name

First NameMiddle NameLast Name
Prefers to be called
Birthdate

MonthDayYear
Date
Gender

MaleFemale
SS #
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Hobbies/activities
Parent/Guardian
Father's Name

First NameLast Name
SS #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer/Occupation
How long?
Mother's Name

First NameLast Name
SS #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer/Occupation
How long?
Dentist
Patient's Dentist
Dental Practice's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Seen

MonthDayYear
Date
Reason
Other dentist/dental specialists now being seen
Reason
Insurance

Orthodontic/Dental Insurance
Primary Policy Holder's Full Name

First NameLast Name
Primary Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Policy Holder's Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Policy Holder's SS #
Relationship to Patient
DOB

MonthDayYear
Date
Employer
Primary Policy Holder's Email
example@example.com
Insurance Company
Group #
ID #
Does this policy have orthodontic coverage?

YesNo
Your answes are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontics evaluation.

For the following questions, please mark yes, no, or don't know/understand (DK/U).
Medical History

Now or in the past, has your child had:
Birth defects or hereditary problems?

YesNoDK/U
Bone fractures or major injuries?

YesNoDK/U
Any injuries to face, head, neck?

YesNoDK/U
Arthritis or joint problems?

YesNoDK/U
Cancer, tumor, radiation treatment or chemotherapy?

YesNoDK/U
Endocrine or thyroid problems?

YesNoDK/U
Diabetes or low sugar?

YesNoDK/U
Kidney problems?

YesNoDK/U
Immune system problems?

YesNoDK/U
History of osteoporosis?

YesNoDK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?

YesNoDK/U
AIDS or HIV positive?

YesNoDK/U
Hepatitis, jaundice, or other liver problems?

YesNoDK/U
Polio, mononucleosis, tuberculosis, pneumonia?

YesNoDK/U
Seizures, fainting spells, neurologic problems?

YesNoDK/U
Mental health disturbance or depression?

YesNoDK/U
History of eating disorder (anorexia, bulimia)?

YesNoDK/U
Frequent headaches or migraines?

YesNoDK/U
High or low blood pressure?

YesNoDK/U
Excessive bleeding or bruising, anemia?

YesNoDK/U
Chest pain, shortness of breath, tire easily, swollen ankles?

YesNoDK/U
Heart defects, heart murmur, rheumatic heart disease?

YesNoDK/U
Angina, arteriosclerosis, stroke or heart attack?

YesNoDK/U
Skin disorder (other than common acne)?

YesNoDK/U
Does your child eat a well-balanced diet?

YesNoDK/U
Vision, hearing, or speech problems?

YesNoDK/U
Frequent ear infections, colds, throat infections?

YesNoDK/U
Asthma, sinus problems, hayfever?

YesNoDK/U
Tonsil or adenoid condition?

YesNoDK/U
Does your child frequently breathe through your mouth?

YesNoDK/U
Has your child ever taken intravenous bisphosponates such as Zometa (zolendromic acid), Aredia (pamidronate), or Didronel (etidronate) for bone disorders or cancer?

YesNoDK/U
Has your child ever taken oral bisphosponates such as Fosamax (alendronate), Acetonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?

YesNoDK/U
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)

YesNoDK/U
Latex (gloves, balloons)

YesNoDK/U
Aspirin

YesNoDK/U
Ibuprofen (Motrin, Advil)

YesNoDK/U
Penicillin

YesNoDK/U
Other antibiotics

YesNoDK/U
Metals (jewelry, clothing snaps)

YesNoDK/U
Acrylics

YesNoDK/U
Plant pollens

YesNoDK/U
Animals

YesNoDK/U
Foods

YesNoDK/U
Other Substance(s)
Dental History

Now or in the past, have you had:
Erupting teeth very early or very late?

YesNoDK/U
Primary (baby) teeth removed that were not loose?

YesNoDK/U
Permanent or extra (supermumerary) teeth removed?

YesNoDK/U
Supermumerary (extra) of congenitally missing teeth?

YesNoDK/U
Chipped or injured primary or permanent teeth?

YesNoDK/U
Any sensitive or sore teeth?

YesNoDK/U
Any lost or broken fillings?

YesNoDK/U
Jaw fractures, cysts, infections?

YesNoDK/U
Any teeth treated with root canals or pulpotomies?

YesNoDK/U
Frequent canker sores or cold sores?

YesNoDK/U
History of speech problems or speech therapy?

YesNoDK/U
Difficulty breathing through nose?

YesNoDK/U
Mouth breathing habit or snoring at night?

YesNoDK/U
Frequent oral habits (sucking finger, chewing pen, etc)?

YesNoDK/U
Teeth causing irritation to lip, cheek or gums?

YesNoDK/U
Tooth grinding or clenching?

YesNoDK/U
Clicking, locking in jaw joints?

YesNoDK/U
Soreness in jaw muscles or face muscles?

YesNoDK/U
Have you ever been treated for “TMJ” or “TMD” problems?

YesNoDK/U
Any broken or missing fillings?

YesNoDK/U
Any serious trouble associated with previous dental treatment?

YesNoDK/U
Has your child ever been diagnosed with gum disease or pyorrhea?

YesNoDK/U
Patient Health Information
Do you think that any of your child's activities affect his/her face, teeth, or jaws? How?
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.
Medication
Taken For
Medication
Taken For
Medication
Taken For
Does your child take antibiotic pre-medication before any dental procedures?
Does your child have (or ever had) a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child's face face or jaws?
Any other physical problems?
Family Medical History

Have the parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
How often does your child brush?
Floss?
Release and Waiver
Parent/Guardian Signature
Date

MonthDayYear
Date
Parent/Guardian Signature
Date

MonthDayYear
Date
Medical History Updates/Changes
Changes
Signature
Date

MonthDayYear
Date
Dental Staff Signature
Date

MonthDayYear
Date
Changes
Signature
Date

MonthDayYear
Date
Dental Staff Signature
Date

MonthDayYear
Date
Changes
Signature
Date

MonthDayYear
Date
Dental Staff Signature
Date

MonthDayYear
Date

Existing Patient Update Form - Child

Patient Information

Parent/Guardian

Dentist

Insurance

Medical History

Dental History

Patient Health Information

Family Medical History

Release and Waiver

Medical History Updates/Changes

Acknowledgement of Receipt of Notice of Privacy Practices