Harmony Ortho NP Form (Child)

Physician's name

Approximate date of last physical exam

Date

YesNo

If yes, please explain:

YesNo

If yes, please explain:

Please answer the following questions:

Rows	Yes	No
Does patient gag easily?
Does patient have frequent ear infections?
Have tonsils and adenoids been removed?

YesNo

If yes, please explain:

YesNo

If yes, please list and explain:

YesNo

If yes, please list:

*foods, medications, environmental (i.e hay fever)

General Dentist (name or name of office)

Approximate date of last cleaning

Date

Please answer the following questions:*

Rows	Yes	No	Explain Here:
Is there any dental work to be completed? (fillings, crowns, etc.)
Have there been any injuries to the face, mouth, or teeth?
Has patient ever sucked their fingers or thumb?
Does patient have any speech problems?
Has patient ever had orthodontic treatment?
Has any family members had orthodontic treatment?
Is patient a mouth breather?
Have you been informed of extra or missing permanent teeth?
Is there pain in the jaw? (please indicate right, left, or both)
Is there popping or clicking in the jaw joint(s)? (please indicate right, left, or both)
Does patient clench or grind?
Does patient regularly have headaches?

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please list:

YesNo

If yes, please indicate right, left, or both

YesNo

If yes, please indicate right, left, or both

YesNo

If yes, please list:

YesNo

If yes, please list:

What is the chief concern that brought you to our office?*

Child Patient Information

Responsible Party No. 1

Responsible Party No. 2

Insurance Information

Emergency Contact Information

Patient Medical History

Patient Dental History