Dental History Form for Patients Under 18

Dental History Form for Patients Under 18
Patient Info
Patient Name*

First NameLast Name
Patient prefers to be called (if Other)
Patient Birth date*

MonthDayYear
Date
Patient Social Security #*
What sex was the patient assigned on their birth certificate?
What is the patient’s current gender identification?
What are the patient’s preferred pronouns?
Patient School
Patient Grade
Patient Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Cell phone*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Patient E-mail address*
example@example.com
Parent/Guardian
Custodial parent(s) name(s)*
Patient lives with (check all that apply)*

Parent 1/GuardianParent 2/GuardianParent 3/GuardianParent 4/GuardianOther
If other, what is the relationship?
Parent 1/Guardian full name*

First NameLast Name
Parent 1/Guardian Occupation
Parent 1/Guardian Email*
example@example.com
Parent 1/Guardian Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1/Guardian cell phone*
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1/Guardian home phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1/Guardian work phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2/Guardian full name*

First NameLast Name
Parent 2/Guardian Occupation
Parent 2/Guardian Email*
example@example.com
Parent 2/Guardian Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2/Guardian cell phone*
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2/Guardian home phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2/Guardian work phone
Please enter a valid phone number.Format: (000) 000-0000.
Dentist
Patient’s Dentist*

First NameLast Name
Address (Dentist)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last seen (Dentist)

MonthDayYear
Date
Reason (Dentist)
Next appointment (Dentist)

MonthDayYear
Date
Other dentists/dental specialists now being seen:

First NameLast Name
Address (Other dentists/dental specialists)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason (Other dentists/dental specialists)
Physician
Patient’s Physician*

First NameLast Name
Address (Patient’s Physician)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last seen (Patient’s Physician)

MonthDayYear
Date
General Information
What concerns you about your child’s teeth?*
What concerns your child about his/her/their teeth?*
How does your child feel about orthodontic treatment?*
Who suggested that your child might need orthodontic treatment?*
Why did you select our office? *
Describe any previous orthodontic treatment or consultations.*
Does your child play a musical instrument?
Sibling 1 Name

First NameLast Name
Sibling 1 Age
Sibling 1 had orthodontic treatment?

YesNo
Sibling 1: If yes, where?
Sibling 2 Name

First NameLast Name
Sibling 2 Age
Sibling 2 had orthodontic treatment?

YesNo
Sibling 2: If yes, where?
Sibling 3 Name

First NameLast Name
Sibling 3 Age
Sibling 3 had orthodontic treatment?

YesNo
Sibling 3: If yes, where?
Sibling 4 Name

First NameLast Name
Sibling 4 Age
Sibling 4 had orthodontic treatment?

YesNo
Sibling 2: If yes, where?
Have any other family members been treated in this office? Please name them.
Financial Responsibility
Who is financially responsible for this account?*

First NameLast Name
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
Home phone (if different from above)
Please enter a valid phone number.Format: (000) 000-0000.
Email (if different from above)
example@example.com
Social Security # (if different from above)
Employer (if different from above)
Who will be responsible for bringing the patient to orthodontic appointments?
Dental Insurance
Primary policy holder’s full name*

First NameLast Name
Birth date (Primary policy holder)

MonthDayYear
Date
Social Security # (Primary policy holder)
Relationship to patient (Primary policy holder)
Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (if not listed above)
Please enter a valid phone number.Format: (000) 000-0000.
Insurance company (Primary policy holder)
Group # (Primary policy holder)
ID # (Primary policy holder)
Does this policy have orthodontic benets? (Primary policy holder)
Secondary policy holder’s full name*

First NameLast Name
Birth date (Secondary policy holder)

MonthDayYear
Date
Social Security # (Secondary policy holder)
Relationship to patient (Secondary policy holder)
Address (Secondary policy holder)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Secondary policy holder)
Please enter a valid phone number.Format: (000) 000-0000.
Employer (Secondary policy holder)
Insurance company (Secondary policy holder)
Group # (Secondary policy holder)
ID # (Secondary policy holder)
Does this policy have orthodontic benets? (Secondary policy holder)
Medical Insurance
Policy holder’s full name (Medical Insurance)*

First NameLast Name
Insurance company (Medical Insurance)*
Patient Health Information
Does the patient take antibiotic pre-medication before any dental procedures?

YesNo
Has the patient ever taken any medications to strengthen their bones? Please describe.
Does the patient currently have (or ever had) a substance abuse problem?
Does the patient currently suffer with, or have suffered in the past with an eating disorder?
Does the patient chew or smoke tobacco?

YesNo
If yes, what is the frequency?
Have you noticed any changes in the patient’s face or jaws?
Is the patient pregnant?

YesNo
Is the patient trying to become pregnant?

YesNo
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Medication
Taken for
Dental History
How often does the patient brush?
How often does the patient floss?
Now or in the past, has the patient had:

Erupting teeth very early or very late?Primary (baby) teeth removed that were not loose?Permanent or extra (supernumerary) teeth removed?Supernumerary (extra) or congenitally missing teeth?Chipped or injured primary or permanent teeth?Any sensitive or sore teeth?Bleeding gums, bad taste or mouth odor?Jaw fractures, cysts, infections?Any teeth treated with root canals or pulpotomies?“Gum boils,” frequent canker sores or cold sores?History of speech problems or speech therapy?Difficulty breathing through nose?Food impaction between the teeth?Mouth breathing habit or snoring at night?History of speech problems?Frequent oral habits (sucking finger, chewing pen, etc.)? Current Yes No Age stoppedFrequent habit of tongue thrust? Current Yes No Age stoppedFrequent habit of fingernail biting? Current Yes No Age stoppedFrequent habit of lip sucking? Current Yes No Age stoppedClicking, locking in jaw joints?Soreness in jaw muscles or face muscles?Ringing in ears, difficulty in chewing or opening jaw?Has the patient ever been treated for “TMJ” or “TMD” problems?Any broken or missing fillings?Any serious trouble associated with previous dental treatment?Has the patient ever been diagnosed with gum disease or pyorrhea?Has the patient ever had an orthodontic consultation or treatment before now?
Medical History
Now or in the past, has the patient had:

Has the patient ever taken intravenous medication for bone disorders or cancer such as bisphosphonates, Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?Has the patient ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?Hereditary or developmental conditions?Bone fractures, or major injuries?Any injuries to face, head, neck?Arthritis or joint problems?Endocrine or thyroid problems?Diabetes or low sugar?Kidney problems?Cancer, tumor, radiation treatment or chemotherapy?Stomach ulcer, hyperacidity, acid reflux?Immune system problems?History of osteoporosis?Gonorrhea, syphilis, herpes, sexually transmitted diseases?AIDS or HIV positive?Hepatitis, jaundice or other liver problem?Polio, mononucleosis, tuberculosis, pneumonia?Seizures, fainting spells, neurologic problems?Mental health disturbance or depression?Vision, hearing, or speech problems?History of eating disorders (anorexia, bulimia)?Has the patient experienced any weight change in the past several months?High or low blood pressure?Excessive bleeding or bruising, anemia?Chest pain, shortness of breath, tire easily, swollen ankles?Heart defects, heart murmur, rheumatic heart disease?Angina, arteriosclerosis, stroke or heart attack?Skin disorder (other than common acne)?Does the patient eat a well-balanced diet?Frequent headaches or migraines?Frequent ear infections, colds, throat infections?Asthma, sinus problems, hayfever?Tonsil or adenoid condition?Does the patient frequently breathe through their mouth?
Does the patient have allergies or reactions to any of the following:

Latex (gloves, balloons)Metals (jewelry, clothing snaps)AcrylicsLocal anesthetics (novocaine, lidocaine, xylocaine)AspirinIbuprofen (Motrin, Advil)PenicillinOther antibioticsPlant pollens
Family Medical History
Have the patient's 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?
Consent
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
Release and Waiver
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company. *
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.*
Today's Date*

MonthDayYear
Date
Medical History Updates or Changes
Changes
Patient Signature
Patient Signature Date

MonthDayYear
Date
Dental Staff Signature
Dental Staff Signature Date

MonthDayYear
Date
Pediatric Sleep Questionnaire

While sleeping does your child....
Snore more than half the time?

YesNoDon't know
Always snore?

YesNoDon't know
Snore loudly?

YesNoDon't know
Have heavy or loud breathing?

YesNoDon't know
Have trouble breathing/struggle to breathe?

YesNoDon't know
Have you ever seen your child stop breathing during sleep?

YesNoDon't know
Does your child....
Tend to breathe through the mouth while awake?

YesNoDon't know
Have a dry mouth upon waking in the morning?

YesNoDon't know
Occasionally wet the bed?

YesNoDon't know
Wake up feeling un-refreshed in the morning?

YesNoDon't know
Have a problem with sleepiness during the day?

YesNoDon't know
Has a teacher/supervisor commented that your child appears sleepy during the day?

YesNoDon't know
Is it hard to wake your child in the morning?

YesNoDon't know
Does your child wake up with headaches?

YesNoDon't know
Did your child stop growing at a normal rate at any time since birth?

YesNoDon't know
Is your child overweight?

YesNoDon't know
My child often....
Does not seem to listen when spoken to directly

YesNoDon't know
Has difficulty organizing tasks

YesNoDon't know
Is easily distracted by extraneous stimuli

YesNoDon't know
Fidgets with hands/feet or squirms in seat

YesNoDon't know
Is always "on the go" or often acts as if "driven by a motor"

YesNoDon't know
Frequently interrupts or intrudes on others (e.g. butts into conversations or games)

YesNoDon't know
Should be Empty:

Dental History Form for Patients Under 18

Patient Info

Parent/Guardian

Dentist

Physician

General Information

Financial Responsibility

Dental Insurance

Medical Insurance

Patient Health Information

Dental History

Medical History

Family Medical History

Consent

Release and Waiver

Medical History Updates or Changes

Pediatric Sleep Questionnaire