Child Form

PATIENT INFORMATION

Date

Name LAST

FIRST

Nickname

Address Street

Apt.#

City

State

Zip

Home Phone

Birth Date

School

E-mail

Who is responsible for the account?

Whom may we thank for referring you to our office?

LAST

FIRST

MIDDLE

LAST

FIRST

MIDDLE

RESIDENCE - STREET

Apt.#

City

State

Zip

RESIDENCE - STREET

Apt.#

City

State

Zip

MAILING - STREET

City

State

Zip

MAILING - STREET

City

State

Zip

(Previous Address - if less than 3 years) STREET

City

State

Zip

(Previous Address - if less than 3 years) STREET

City

State

Zip

OCCUPATION

EMPLOYER

YEARS EMPLOYED

EMPLOYER

YEARS EMPLOYED

DATE OF BIRTH

HOME PHONE #

WORK PHONE #

HOME PHONE #

WORK PHONE #

E-MAIL

INSURANCE INFORMATION

Insured’s Name

Insurance Company

Group No.

Local No.

Insurance Co. Address

Telephone #

Do you have dual coverage?

Yes No

Insured’s Name

Insurance Company

Group No.

Local No.

Insurance Co. Address

Telephone #

EMERGENCY INFORMATION

Name of nearest relative not living with you

Complete Address

Telephone

CONTINUED ON REVERSE

Craig Davis, DDS, MSD ▪ 5200 Snyder Lane ▪ Rohnert Park, CA 94928

707 585 2500 ▪ WWW.CraigDavisorthodontics.com

Diplomate, American Board of Orthodontics

CONFIDENTIAL HEALTH HISTORY

Patient Name:

Date of Birth:

I. SELECT APPROPRIATE ANSWER(Leave blank if you do not understand the question)

Yes No

Is your general health good?

If NO, explain

Yes No

Has there been a change in your health within the last year?

If YES, explain

Yes No

Have you gone to the hospital or emergency room or had a serious illness in the last three years?

If YES, explain

Yes No

Are you being treated by a physician now? If YES, explain

Date of last medical exam?

Reason for exam

Yes No

Have you had problems with prior dental treatment?

If YES, explain

Date of last dental exam

Name of last treating dentist

Yes No

Are you in pain now?

If YES, explain

II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING? (Check Box if "Yes")

Chest pain (angina)

Blood in stools

Frequent vomiting

Fainting spells

Diarrhea or constipation

Jaundice

Recent significant weight loss

Frequent urination

Dry mouth

Fever

Difficulty urinating

Excessive thirst

Night sweats

Ringing in ears

Difficulty swallowing

Persistent cough

Headaches

Swollen ankles

Coughing up blood

Dizziness

Joint pain or stiffness

Bleeding problems

Blurred vision

Shortness of breath

Blood in urine

Bruise easily

Sinus problems

III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Check Box if "Yes")

Heart disease

AIDS/HIV

Psychiatric care

Family history of heart disease

Surgeries

Osteoporosis

Heart attack

Hospitalization

Thyroid disease

Artificial joint

Diabetes

Asthma

Stomach problems or ulcers

Family history of diabetes

Hepatitis

Heart defects

Tumors or cancer

Sexual transmitted disease

Heart murmurs

Chemotherapy

Herpes

Rheumatic fever

Radiation

Canker or cold sores

Skin disease

Arthritis, rheumatism

Anemia

Hardening of arteries

Emphysema or other lung disease

Liver disease

High blood pressure

Kidney or bladder disease

Eye disease

Seizures

Stroke

Transplants

Cosmetic surgery

Eating disorders

Tuberculosis

IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING? (Check Box if "Yes")

Aspirin

Valium

Tetracycline

Darvon

Demerol

Vicodin

Codeine

Penicillin

Percodan

Local anesthetic (Novacaine or Xylocaine)

Latex

Food

Nitrous oxide

Erythromycin

Metal

Others:

V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS? (Check Box if "Yes")

Recreational drugs

Tobacco in any form

Antibiotics

Over-the-counter medicines

Alcohol

Supplements

Weight loss medications

Bisphosphonate (Fosamax)

Aspirin

Please list:

DENTALHISTORY

Patient’s Dentist

Date of last visit

VI. WOMEN ONLY

Yes No

Are you or could you be pregnant?

If YES, what month?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

VII. ALL PATIENTS

Yes No

Do you have or have you had any other diseases or medical problems NOT listed on this form?

If YES, please explain:

Yes No

Have you ever been pre-medicated for dental treatment? If YES, why

Yes No

Have you ever taken Fen-phen? If YES, when

Yes No

Is there any issue or condition that you would like to discuss with the dentist in private?

The practice of dentistry involves treating the whole person. If the doctor determines that there may be a potentially medically-compromised situation, a medical consultation may be needed prior to commencement of orthodontic treatment.

I authorize the orthodontist to contact my physician.

Parent/ Guardian Signature:

Date:

Physician’s Name:

Phone Number:

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Parent / Guardian Signature

Date:

ORTHODONTIC INFORMATION

Reason for consultation?

Who noticed orthodontic problem?

Dentist

Parent

Patient

Other

Yes

Other orthodontic examinations?

Other orthodontic treatment?

Is patient self-conscious about his/her teeth?

Has anyone in your family had orthodontic treatment?

Name and ages of other children in your family

PHOTOGRAPHIC SUBJECT MODEL RELEASE:

I authorize Dr. Craig Davis to publish photographs in which I am a recognizable subject. I understand there will be no renumeration to me or anyone representing me as a result of appearing in the aforementioned photographs.

Yes

, have receieved a copy of this office’s Notice of Privacy Practices.

Parent / Guardian Signature

Date:

Welcome to our office. So that we may become better acquainted, please complete the following confidential information.

PATIENT INFORMATION

FATHER

MOTHER

INSURANCE INFORMATION

EMERGENCY INFORMATION

Craig Davis, DDS, MSD ▪ 5200 Snyder Lane ▪ Rohnert Park, CA 94928

707 585 2500 ▪ WWW.CraigDavisorthodontics.com

Diplomate, American Board of Orthodontics

CONFIDENTIAL HEALTH HISTORY

I. SELECT APPROPRIATE ANSWER(Leave blank if you do not understand the question)

II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING? (Check Box if "Yes")

III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Check Box if "Yes")

IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING? (Check Box if "Yes")

V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS? (Check Box if "Yes")

DENTALHISTORY

VI. WOMEN ONLY

VII. ALL PATIENTS

ORTHODONTIC INFORMATION

PHOTOGRAPHIC SUBJECT MODEL RELEASE: