CHILD PATIENT INFORMATION
first name
last name
Date
Date of Birth
Age
Sex
Height
Weight
Address
City
Zipcode
Phone
Cell Phone
Insurance ID#
Hobbies
Pets
Brothers? Name & Age
Sisters? Name & Age
Has anyone in your family had orthodontic work done in our office?
Who referred you? / How did you hear about our office?
Patient's Dentist
Last Dental Check-up
PARENT INFORMATION
Marital Status
other
divorced
married
If 'Other', explain
Mother's Name
Date of Birth
Occupation
Employed by
Business Address
Business Phone
Home address & phone (if different from patient's)
Father's Name
Date of Birth
Occupation
Employed by
Business Address
Business Phone
Home address & phone (if different from patient's)
Additional Contact Information (e.g. Step Parent)
Name
Date of Birth
Relationship to Patient
Occupation
Employed by
Business Address
Business Phone
Home address & phone (if different from patient's)
Additional Contact Information
Name
Date of Birth
Relationship to Patient
Occupation
Employed by
Business Address
Business Phone
Home address & phone (if different from patient's)
INSURANCE INFORMATION
Your insurance benefits are a contract between you and your carrier. However, with your permission, we would be happy to assist you in obtaining your benefits. Please complete the following as completely as you can, so we can be as helpful as possible.
Primary Dental Insurance Co.
Group #
Phone #
Subscriber is
Subscriber Date of Birth
Subscriber ID
Secondary Dental Insurance Co.
Group #
Phone #
Subscriber is
Subscriber Date of Birth
Subscriber ID
Additional Information
Relationship to Patient
Primary Insurance Co.
Group #
Phone #
Subscriber is
Subscriber Date of Birth
Subscriber ID
Secondary Insurance Co.
Group #
Phone #
Subscriber is
Subscriber Date of Birth
Subscriber ID
HEALTH HISTORY
Your health is important to us. In order to provide excellent care with safety, it is necessary to become acquainted with vital information related to each patient. Thus, it is extremely important that you answer the following questions as accurately as possible. If you have any questions regarding the information requested, please feel free to ask the doctor or a member of the staff for assistance.
Patient Name
Birthdate
Age
Have you been a patient in a hospital during the past 2 years?
No
Yes
Have you been under the care of a physician during the past 2 years?
No
Yes
Have you taken any kind of medicine or drugs during the past 2 years?
No
Yes
Please list this medication
Please list all drugs you are currently taking
Are you allergic to Penicillin(s)?
No
Yes
Are you allergic to any other medications?
No
Yes
>>> If yes, please list them here
Do you have a latex allergy?
No
Yes
Have you had any excessive bleeding requiring special treatment?
No
Yes
List any serious medical condition(s)
Do you have any allergies / sensitivities
No
Yes
Have you taken any bisphosphonates or osteoporosis / bone cancer meds. within last 5 years?
No
Yes
Do you smoke?
No
Yes
>>> If yes, how much?
Women: Are you pregnant?
No
Yes
>>> If yes, how many months?
Is there a possibility that you are pregnant?
No
Yes
>>> Are you nursing?
No
Yes
Do you have ADD?
No
Yes
>>> ADHD?
No
Yes
>>> Any part of the Autism spectrum?
No
Yes
Have you ever tested HIV positive?
No
Yes
Do you snore?
No
Yes
Have you been told that you stop breathing when you are sleeping?
No
Yes
Do you suffer from frequent or severe headaches?
No
Yes
>>> Back pain?
No
Yes
>>> Neck pain?
No
Yes
Do you have any other health history or Medical Conditions we did not ask about?
No
Yes
Physician's Name, City, and Phone Number
The above medical history is accurate and current to the best of my knowledge. I understand I need to notify this office whenever there is a change in my health history.
Name of person filling out this form
Date
Your "Smiles" Questionaire
Patient's Name
Date
Have you had any accidents involving your teeth?
No
Yes
Have you ever had an injury to your face, neck or jaws?
No
Yes
Do you have difficulty in opening your mouth wide?
No
Yes
Jaws ever click or pop?
No
Yes
Do you have pain in front of the ears?
No
Yes
Do you have any pre-existing T.M.J. problems?
No
Yes
Check habits
Nail Biting
No
Yes
Thumbsucking
No
Yes
Mouthbreathing
No
Yes
Lip Biting
No
Yes
Pencil Biting
No
Yes
Night Grinding
No
Yes
Other
No
Yes
If other, explain
Have you ever had any difficulty with past dental treatment?
No
Yes
Please explain
Do you feel that your teeth are...
Too small or short?
No
Yes
Crooked or crowded?
No
Yes
Too large or too long?
No
Yes
Misshaped (uneven Pointed)?
No
Yes
Off Color?
No
Yes
Do you feel your teeth 'stick out too much' ('buck teeth')?
No
Yes
Are there spaces between your teeth that you do not like?
No
Yes
Does too much gum tissue show when you smile?
No
Yes
Does too little gum tissue show when you smile?
No
Yes
Have you had previous orthodontic treatment (including braces or other appliances?)
No
Yes
If so, when and by whom?
Are there other dental issues not listed above that you would like to discuss or have treated?
No
Yes
Explain
