Required fields *
ALL fields are strongly encouraged
CHILD PATIENT INFORMATION
Full Legal Name
Preferred Name
Date
Date of Birth
Sex at birth
Male
Female
Preferred Pronouns
Height
Weight
Address
City
Zipcode
Cell Phone
Email
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 of Parents
Married
Divorced
Other
If 'Other', explain
Parent's Name (e.g. Mother)
Date of Birth
Occupation
Employed by
Parent's Name (e.g. Father)
Date of Birth
Occupation
Employed by
Additional Contact Information (e.g. Step Parent)
Name
Date of Birth
Relationship to Patient
Occupation
Employed by
Additional Contact Information (e.g. Step Parent)
Name
Date of Birth
Relationship to Patient
Occupation
Employed by
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
HEALTH HISTORY
Have you been a patient in a hospital during the past 2 years?
Yes
No
Have you been under the care of a physician during the past 2 years?
Yes
No
Have you taken any kind of medicine or drugs during the past 2 years? Please list them here.
Are you allergic to Penicillin(s) / Do you have any other allergies or sensitivites? If yes, please list them here
Do you have a latex allergy?
Yes
No
Have you had any excessive bleeding requiring special treatment?
Yes
No
List any serious medical condition(s)
Have you taken any bisphosphonates or osteoporosis / bone cancer meds. within last 5 years?
Yes
No
Do you smoke? If yes, how much?
Do you have diabetes?
Yes
No
Do you have hypertension (high blood pressure)?
Yes
No
Do you have high cholesterol?
Yes
No
Is there a possibility that you are pregnant? If yes, how many months?
>>> Are you nursing?
Yes
No
Do you have ADHD?
Yes
No
>>> Any part of the Autism spectrum?
Yes
No
Have you ever tested HIV positive?
Yes
No
Do you snore?
Yes
No
Have you been told that you stop breathing when you are sleeping?
Yes
No
Do you suffer from frequent or severe headaches?
Yes
No
Back pain? / Neck pain?
Do you have any other health history or Medical Conditions we did not ask about? If yes, please explain
Physician's Name, City, and Phone Number
Your "Smile" Questionaire
Have you had any accidents involving your teeth?
Yes
No
Have you ever had an injury to your face, neck or jaws?
Yes
No
Do you have difficulty in opening your mouth wide?
Yes
No
Do your jaws ever click or pop?
Yes
No
Do you have pain in front of the ears?
Yes
No
Do you have any pre-existing T.M.J. problems?
Yes
No
Check habits
Nail Biting
Yes
No
Thumbsucking
Yes
No
Mouthbreathing
Yes
No
Lip Biting
Yes
No
Pencil Biting
Yes
No
Night Grinding
Yes
No
Other
Have you ever had any difficulty with past dental treatment? Please explain
Do you feel that your teeth are...
Too small or short?
Yes
No
Crooked or crowded?
Yes
No
Too large or too long?
Yes
No
Misshaped (uneven Pointed)?
Yes
No
Off Color?
Yes
No
Do you feel your teeth 'stick out too much' ('buck teeth')?
Yes
No
Are there spaces between your teeth that you do not like?
Yes
No
Does too much gum tissue show when you smile?
Yes
No
Does too little gum tissue show when you smile?
Yes
No
Have you had previous orthodontic treatment (including braces or other appliances?) If so, when and by whom?
Are there other dental issues not listed above that you would like to dicuss or have treated. Please Explain?
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
Submit