CHILD MEDICAL HISTORY FORM
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational.
We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.
1. TELL US ABOUT YOUR CHILD:
Today's Date:
Child's Name:
Last
First
MI
Child's Birth date:
Age
Nickname:
Male
Female
School:
Grade:
Hobbies/Sports:
Child's Home#:
SS#:
Child's Home Address
City
State
Zip
2. WHO IS ACCOMPANYING THE CHILD TODAY?
Name:
Relation:
Do you have legal custody of this child?
Y
N
Whom may we Thank for referring you?
List brothers/sisters with age:
General Dentist:
Last Exam Date:
Any cavities?
Parent's Marital Status:
Single
Married
Widowed
Divorced
Separated
3. PARENT'S INFORMATION
Mother
Step Mother
Guardian
Name:
DOB:
Wk#:
Ext.
Hm#:
Employer:
How long at current job?
Title:
SS#:
DL#:
Email:
Father
Step Father
Guardian
Name:
DOB:
Wk#:
Ext.
Hm#:
Employer:
How long at current job?
Title:
SS#:
DL#:
Email:
4. PERSON RESPONSIBLE FOR ACCOUNT
Name:
Relation:
Billing Address
City
State
Zip
Cell phone #:
Hm#:
DL#:
Employer:
Wk#:
Ext.
SS#:
Email:
5. PRIMARY DENTAL INSURANCE
Dental Coverage?
Yes
No
Ortho?
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone#:
Group#(Plan, local, or Policy#):
Policy Owner's Name:
Relationship to Patient:
Policy Owner's DOB:
Policy Owner's SS#:
6. DOES/DID THE CHILD HAVE ANY OF THE FOLLOWING?
Y
N
Clenching/Grinding Teeth
Y
N
Lip Sucking/Biting
Y
N
Mouth Breather
Y
N
Nail Biting
Y
N
Nursing Bottle Habits
Y
N
Speech Problems
Y
N
Thumb/Finger Sucking
Y
N
Tongue Thrust
Patient Name:
7. WHAT WOULD YOU LIKE ORTHODONTICS TO ACCOMPLISH?
Has the child ever been evaluated or had orthodontic treatment before?
Y
N
Have there been any injuries to the face, mouth, teeth or chin?
Y
N
List any musical instruments played
Have adenoids or tonsils been removed?
Y
N
Has your child been informed of any missing or extra permanent teeth?
Y
N
Has the child even had any pain / tenderness in his / her jaw joint (TMI/TMD)?
Y
N
Does the child brush his/her teeth daily?
Y
N
Floss his/her teeth daily?
Y
N
Child's Physician:
Phone#:
Date of Last Visit:
Is child currently under the care of a physician?
Y
N
Has puberty begun?
Y
N
Has menstruation begun? (Girls)
Y
N
Please describe the child's current physical health:
Good
Fair
Poor
Please list all drugs that the child is currently taking:
Please list all drugs/things that the child is allergic to:
8. HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS:
Y
N
Abnormal Bleeding
Y
N
Allergies to Any Drugs
Y
N
Allergic to Latex/Metals
Y
N
Allergic to Plastics
Y
N
Any Hospital Stays
Y
N
Any Operations
Y
N
Asthma
Y
N
Cancer
Y
N
Congenital Heart Defect
Y
N
Convulsions/Epilepsy
Y
N
Diabetes
Y
N
Handicaps/Disabilities
Y
N
Hearing Impairment
Y
N
Heart Murmur
Y
N
Hemophilia
Y
N
Hepatitis
Y
N
HIV +/ AIDS
Y
N
Kidney/Liver Problems
Y
N
Rheumatic/Scarlet Fever
Y
N
Tuberculosis (TB)
9. I understand that the information that I have given is correct to the best of my knowledge, that is will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Date
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If this office accepts insurance, I understand that I am responsible for payment of services renderedand also responsible for paying any co-payment and deductibles that my insurance does not cover. I herby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
Date
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