Health History Form - Patients Under Age 18

Today's Date

Date

PATIENT

Patient's Name*

First NameLast Name

Prefers to be called

Hobbies, activities

Birth Date*

Date

Gender*

MaleFemale

Identifies as*

MaleFemaleNon-binary

School

Grade

Home Address*

Street Address

apt or unit #

CityState / Province

Postal / Zip CodeCountry

Home Phone Number

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

PARENT/GUARDIAN

Custodial parent(s) name(s)*

Patient lives with (check all that apply)

Parent Information #1

Full Name*

Title

Occupation

E-mail*

example@example.com

Home Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Work Phone Number

Area CodePhone Number

Parent Information #2

Full Name

First NameLast Name

Title

Occupation

Email

example@example.com

Home Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Area CodePhone Number

Work Phone Number

Area CodePhone Number

DENTIST

Patient's Dentist*

Phone Number

Area CodePhone Number

Last Seen

Reason

Next Appointment

Other dentists/dental specialists now being seen:

Reason

GENERAL INFORMATION

What concerns you about your child's teeth?*

What concerns your child about his/her 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?

YesNo

Brother/Sister Information #1

Name

First NameLast Name

Age

Had Orthodontic Treatment?

YesNo

If yes, where?

Brother/Sister Information #2

Name

First NameLast Name

Age

Had Orthodontic Treatment?

YesNo

If yes, where?

Brother/Sister Information #3

Name

First NameLast Name

Age

If yes, where?

Had Orthodontic Treatment?

YesNo

Brother/Sister Information #4

Name

First NameLast Name

Age

Had Orthodontic Treatment?

YesNo

If yes, where?

Have any other family members been treated in this office? Please name them.

DENTAL INSURANCE

Do you have dental insurance?*

YesNo

Please attach copies of the FRONT and BACK of your dental insurance card

Browse Files

please attach 2 files - front and back

If you've attached pictures of the front and back of your insurance card, please include the subscriber's date of birth below.

If you do not have a copy of your dental insurance card, please fill out the information below. We will need every field completed in order to verify any coverage and benefits.

Primary Policy Holder's Full Name

First NameLast Name

Birth Date

Date

Social Security #

Relationship to Patient

Phone Number (if not listed above)

Area CodePhone Number

Zip Code

Employer

Insurance Company

Group #

ID #

Does this policy have orthodontic benefits?

YesNoDon't Know

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

For the follow questions, please mark yes, no or don't know/understand (DK/U)

MEDICAL HISTORY

Now or in the past, has your child had:*

	Yes	No	DK/U
Birth defects or hereditary problems
Bone fractures or major injuries?
Any injuries to face, head or neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice, or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problems?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
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 your child eat a well-balanced diet?
Vision, hearing or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Has your child ever taken oral disphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?

Has your child had allergies or reactions to any of the following?*

	Yes	No	DK/U
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Metals (jewelry, clothing snaps)
Acrylics
Other substances (if yes, please specify below)

If you checked 'Yes' for "Other substances", please specify below:

DENTAL HISTORY

Now or in the past, has your child had:*

	Yes	No	DK/U
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?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Frequent oral habits (sucking finger, chewing pen, etc)?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?

RELEASE AND WAIVER

I authorize release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company.

Parent/Guardian Signature*

Date

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 child's medical or dental health.

Parent/Guardian Signature*

Date