Smilesbyaos Child Patient Health History Forms

PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

Patient’s name Last

First

Middle

Address Street

City

Zip

Nickname

Birthday

Parent or guardian name

Email Address

Contact (Phone Number)

Whom may we thank for referring you to our office?

DENTAL INSURANCE INFORMATION

Insured’s Name

ID # or SS #

Subscriber's D.O.B.

Insurance Company

Insurance Company Phone #

Group #

Local # (Union Employees)

Do you have dual coverage?

Yes No

Insured’s Name

ID # or SS #

Insurance Company

Insurance Company Phone #

Group #

Local # (Union Employees)

MEDICAL HISTORY

Physician

Date of Last Visit

Address

Phone

Please circle Yes or No (If Yes, please fill in details)

Yes No

Is the patient taking any medication?

Yes No

Is the patient allergic to any medication?

Yes No

History of a major illness?

Yes No

Has the patient had any operations?

Yes No

Ever been involved in a serious accident?

Yes No

Have seen a physician in the last 12 months? Why?

Female Patients only:

Yes No

Has menstruation started?

Yes No

Is the patient pregnant?

Check any of the medical conditions below that you have had or currently have.

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY

General Dentist

Date of last visit

What concerns you most about your teeth?

Yes No

Is the patient presently in any dental pain?

Yes No

Ever experienced any unfavorable reaction to dentistry?

Yes No

Has the patient ever seen an orthodontist? If yes, who and when?

Yes No

Has the patient ever lost or chipped any teeth?

Yes No

Have there been any injuries to face, mouth, or teeth?

Yes No

Is any part of your mouth sensitive to temperature? Where?

Yes No

Is any part of your mouth sensitive to pressure? Where?

Yes No

Do gums bleed when brushing?

Yes No

Any type of thumb or tongue habit?

Yes No

Is the patient a mouth breather?

Yes No

Do teeth or jaws ever feel uncomfortable first thing in the morning?

Yes No

Experience jaw clicking or popping?

Yes No

Aware of clenching or grinding teeth during the day?

Yes No

Experience “tension” headaches?

Yes No

Has the patient ever experienced chronic ringing in the ears?

Yes No

Is the patient sensitive or self-conscious about his/her teeth?

BENEFITS

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Michael Bicknell to perform a complete orthodontic evaluation.

Signature

Date: