Health History Form | Genesis Orthodontics

Patient's Name: Last

First

Middle

Address: Street

City

State

Zip

Nickname:

Birthdate:

Age:

Sex:

Phone number we should use to confirm appointments:

Text number we should use to confirm appointments:

Email address we can use for appointment reminders:

Who may we thank for referring you to our office?

Patient's hobbies/interests:

How would you describe your child's temperament?

School:

Grade:

Father's Name: Last

First

Middle

Address: Street

City

State

Zip

Social Security #:

Birthdate:

Home Phone:

Cell:

Email:

Employer:

Occupation:

Employer Address:

Work Phone:

Mother's Name: Last

First

Middle

Address: Street

City

State

Zip

Social Security #:

Birthdate:

Home Phone:

Cell:

Email:

Employer:

Occupation:

Employer Address:

Work phone:

If divorce is involved, who is the custodial parent?

May patient information be released to the non-custodial parent?

Yes No

Primary Dental Insurance Company & Address:

Subscriber's Name:

Subscriber's Social Security Number:

Relationship to Patient:

Subscriber's Address:

Subscriber's Date of Birth:

Subscriber's Employer:

Subscriber's ID:

Group #:

Secondary Dental Insurance Company & Address:

Subscriber's Name:

Subscriber's Social Security Number:

Relationship to Patient:

Subscriber's Address:

Subscriber's Date of Birth:

Subscriber's Employer:

Subscriber's ID:

Group #:

What is your child's main orthodontic problem as you (or they) see it?

Is your child sensitive about the appearance of his/her teeth?

Is your child sensitive about the appearance of any facial features? (nose, chin, lips, etc.)

What do you consider the main benefits of orthodontic treatment?

Cosmetic Functional Psychological/Emotional

Other

How does your child feel about wearing braces?

Has your child ever had an orthodontic consultation?

If yes, When?

Has anyone else in the family received orthodontic treatment?

If yes, Who?

Name of your general dentist:

Name of previous orthodontist, if applicable:

Frequency of dental checkup:

Once/year Twice/year

Date of last dental exam:

Other:

If you answered yes to any of the above, please explain:

Has the patient's shoe size changed recently?

Has your child begun Puberty?

Yes No

If your child is a girl, has menstruation begun?

Yes No

If your child is a boy, has their voice changed?

Yes No

Is the patient adopted?

If yes, is the patient aware of this?

Does any genetically related family member have a similar facial/dental appearance:

List name(s) and age(s) of siblings:

Patient's Physician:

Approximate date of last exam:

Is the patient currently seeing a Physical Therapist or Chiropractor?

Yes No

If yes, name & address:

Is the patient in good health?

Yes No

If no, please explain:

Please list any medications the patient is currently taking:

List any drug allergies or sensitivities:

Right or left handed:

Other:

If you answered yes to any of the above, please explain:

Patient Information

Parent and Responsible Party Information

Insurance Information

Dental History

Genetic History

Medical History