Child medical history form

Welcome to our practice! All of us at Nadeau Orthodontics, P.A. thank you for choosing us for your orthodontic needs. We pride ourselves in ensuring our patients and their families receive both outstanding orthodontic treatment and exemplary customer service. In order for us to fulfill our promise please take a few minutes to complete our patient registration, medical health history, and dental health history form. Thank you!

PATIENT REGISTRATION

Patient’s Last Name:

First:

Middle:

Address:

City:

State:

Zip:

Phone

Email Address:

Birth Date:

Age:

Gender Assigned at Birth

Whom should we thank for referring you to our office?

Have any of your friends or other family members been treated in our office?

Favorite sports, Hobbies & Avocations:

Musical instrument played:

Parent/Guardian

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email address:

Employer:

Employer Address:

Position:

Parent/Guardian

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Employer:

Employer Address:

Position:

Person responsible for the account:

Person responsible for making appointments:

Person to contact in case we cannot reach you:

Phone:

ORTHODONTIC INSURANCE

Primary Coverage

Insurance Co:

Phone:

Group Number:

Subscriber Name:

Subscriber SS #:

Subscriber Date of Birth:

Secondary Coverage

Insurance Co:

Phone:

Group Number:

Subscriber Name:

Subscriber SS#:

Subscriber Date of Birth:

207-985-8999
63 Portland Road, Suite 5, Kennebunk, Maine 04043
www.nadeauortho.com

CHILD MEDICAL HEALTH HISTORY

Your responses to the following questions are for our office records only and will be considered confidential.

Describe your child’s overall health:

Excellent
Good
Fair
Poor

Yes
No
Has your child ever been hospitalized?

If yes, please explain:

Yes
No
Is your child allergic to any drug or other substance?

If yes, please list:

Yes
No
Is your child allergic to latex?

Yes
No
Is your child currently taking any drugs or medication?

If yes, please list:

Yes
No
Has a health care provider ever informed you that your child requires pre-medication before dental treatment?

Yes
No
Has your child’s tonsils and/or adenoids been removed?

PLEASE CIRCLE ALL CONDITIONS THAT APPLY TO YOUR CHILD.

Heart murmur

Endocrine or thyroid problems

Immune system disorders

Heart surgery

Kidney problems

AIDS or HIV positive

Rheumatic/ Scarlet Fever

Diabetes

Cancer

Heart pacemaker

Hepatitis, jaundice, liver disorders

Epilepsy, seizures, or fainting spells

Artificial heart valve

Tumor treatment

Neurological problems

Chest pain or shortness of breath

Polio, Mono, Tuberculosis

Mental health problems

Tires easily

Pneumonia

Emotional or behavioral problems

Artificial joints

Vision, hearing, or speaking problems

Sinus problems

High or Low blood pressure

Eye, ear, nose, or throat condition

Frequent headaches

Bleeding disorder or anemia

Asthma

TMJ problems

Birth defects or hereditary problem

Hay fever

Tactile defensive

Past operations

Past or present substance abuse problems

Smoking or other tobacco use

PLEASE INITIAL HERE IF NONE OF THE ABOVE CONDITIONS APPLY TO YOUR CHILD.

Males:

Has your child’s voice changed?

If yes, when?

Females:

Has your child started menstruating?

If yes, when?

CHILD DENTAL HEALTH HISTORY

Name of your child’s dentist:

Last visit:

How often does your child brush their teeth?

Floss?

What is your primary concern? Why are you here?

Who first noticed a need for orthodontic treatment?

What is your main concern regarding your child’s orthodontic tx?
QUALITY
DISCOMFORT
COST
APPEARANCE
TIME

PLEASE CHECK THE LINE IF THE CONDITION(S) APPLIES TO YOUR CHILD

Started teething very early or late?

Limited jaw opening?

Missing teeth?

Pain in the jaw or muscles of the face?

Extra (supernumerary) teeth?

Teeth grinding?

Chipped or otherwise injured teeth?

Thumb or finger sucking habit?

Until what age?

Jaw fractures, cysts, or infections?

Abnormal swallowing habit?

Extracted teeth?

Speech problems?

Teeth sensitive to hot or cold?

Mouth breathing habit?

Loose or broken fillings?

Snoring?

Food impaction between teeth?

Under or over developed jaw?

Teeth irritating the cheek or gums?

Relatives with similar teeth or jaw relationships?

Wisdom teeth problems?

Previous orthodontic treatment?

Sore or bleeding gums?

Previous orthodontic evaluation?

How long ago?

I HAVE READ AND UNDERSTAND THE ABOVE QUESTIONS. I WILL NOT HOLD DR. NADEAU OR ANY MEMBER OF HIS STAFF RESPONSIBLE FOR ANY ERRORS OR OMISSIONS THAT I HAVE MADE IN THE COMPLETION OF THIS FORM. IF THERE ARE ANY CHANGES LATER TO THIS HISTORY RECORD OR MEDICAL / DENTAL STATUS I WILL INFORM THIS PRACTICE.

Signature of parent or guardian

Date

PATIENT REGISTRATION

Parent/Guardian

Parent/Guardian

ORTHODONTIC INSURANCE

Primary Coverage

Secondary Coverage

CHILD MEDICAL HEALTH HISTORY

*Your responses to the following questions are for our office records only and will be considered confidential.*

PLEASE CIRCLE ALL CONDITIONS THAT APPLY TO YOUR CHILD.

CHILD DENTAL HEALTH HISTORY

PLEASE CHECK THE LINE IF THE CONDITION(S) APPLIES TO YOUR CHILD

Your responses to the following questions are for our office records only and will be considered confidential.