Child Patient Health History
01: Tell Us About Your Child
Today's Date
*
-
Month
-
Day
Year
Date
Child's Nickname
Child's Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
School
Grade
Hobbies/Sports
Child's Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's General Dentist
*
Last Appointment Date
*
-
Month
-
Day
Year
Date
02: Who is Accompanying Your Child?
Name
*
First Name
Last Name
Relation
*
Do you have legal custody of this child?
*
Yes
No
Whom may we thank for referring you?
List child's brothers and/or sisters with age:
Parent's Marital Status
Single
Married
Partnered
Separated
Divorced
Widowed
03: Parent's Information
Mother's Information
Name
*
First Name
Last Name
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
How long at current job
Job Title
Father's Information
Name
*
First Name
Last Name
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
How long at current job
Job title
Person Responsible for Account
Name
*
First Name
Last Name
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who is responsible for making appointments?
Name
*
First Name
Last Name
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Orthodontic Insurance
Do you have orthodontic coverage?
*
Yes
No
Insurance Company Name
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Group # (Plan, Local, or Policy #)
Policy Owner's Name
First Name
Last Name
Relationship to Patient
Policy Owner's Date of Birth
-
Month
-
Day
Year
Date
Policy Owners Social Security #
Policy Owner's Employer
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance Information
Do you have secondary insurance?
*
Yes
No
Secondary Insurance Company
Secondary Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Insurance Group # (Plan, Local, or Policy #)
Secondary Insurance Policy Owner's Name
First Name
Last Name
Relationship to Patient
Policy Owner's Birth Date
-
Month
-
Day
Year
Date
Policy Owner's Social Security #
Policy Owner's Employer
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What are the main concerns that you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?
*
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
*
Yes
No
List any musical instruments played
Have adenoids or tonsils been removed?
*
Yes
No
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
Is your child currently under the care of a physician?
*
Yes
No
Child's Physician
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Visit
-
Month
-
Day
Year
Date
Has puberty begun?
*
Yes
No
Has menstruation begun? (Girls)
Yes
No
Any chance of pregnancy? (Girls)
Yes
No
Please describe your child's current physical health
Good
Fair
Poort
Please list any allergies your child has:
Please list all drugs that your child is currently taking
Please list all drugs that your child is allergic to
Has your child had any of the following medical problems?
Abnormal Bleeding
ADD / ADHD
Allergic to Latex / Metals
Allergies to any Drugs
Any Hospital Stays
Any Operations
Artificial Bones / Joints / Valves
Asthma Lupus
Cancer
Convulsions / Epilepsy
Diabetes
Handicaps / Disabilities
Heart Murmur
Hemophilia
Hepatitis
Kidney / Liver Problems
Rheumatic / Scarlet Fever
Tuberculosis (TB)
HIV+ / AIDS
Has Your Child Ever Experienced Any Of The Following?
Clenching / Grinding Teeth
Lip Sucking / Biting
Mouth Breather
Nail Biting
Nursing Bottle Habits
Speech Problems
Thumb / Finger Sucking
Tongue Thrust
Neighbor or Relative not living with you:
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that the information that I have given is correct to the best of my knowledge, that it will beheld in the strictest of confidence and 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 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 payment and copayment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable tome) directly to this office.
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
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