Health-History-Child-Form

Last Name:

First Name:

MI:

Preferred Name:

Birth Date:

Gender:

Male Female

Address: Street, City, State, Zip Code

Home Phone Number:

Dentist Name:

Dentist Address: Street, City, State, Zip Code

Dentist Phone Number:

Dentist Email:

Family in treatment with us:

How did you hear about us:

PARENT/GUARDIAN INFORMATION

Full Name:

Relation:

Mother Father Guardian

Other:

Address (if different): Street, City, State, Zip Code

Home Phone Number (if different):

Mobile Phone Number:

Work Phone Number:

Email Address:

Financially Responsible Party?

Yes No

Full Name:

Relation:

Mother Father Guardian

Other:

Address (if different): Street, City, State, Zip Code

Home Phone Number (if different):

Mobile Phone Number:

Work Phone Number:

Email Address:

Financially Responsible Party?

Yes No

Who will accompany patient to appointments?

Mother

Father

Guardian

Grandparents

Other:

Who does the patient live with?

Mother

Father

Guardian

Grandparents

Other:

DENTAL INSURANCE INFORMATION

Primary Insurance

Insurance Company:

Employer:

Policy Holder Full Name:

Policy Holder SSN:

Policy Holder DOB:

Please attach photos of the front and back of your insurance card:

Front:

Back:

Secondary Insurance (if applicable)

Insurance Company:

Employer:

Policy Holder Full Name:

Policy Holder SSN:

Policy Holder DOB:

Please attach photos of the front and back of your insurance card:

Front:

Back:

Has your child ever been diagnosed with the following?

anemia/bleeding disorder

Yes No

anxiety/mental health disorder

Yes No

arthritis/joint disorder

Yes No

asthma/sinus disorder

Yes No

birth defects/hereditary disorder

Yes No

cancer/tumor

Yes No

chemotherapy/radiation treatment

Yes No

chest pain/stroke/heart attack

Yes No

diabetes/low blood sugar

Yes No

eating disorder

Yes No

endocrine/thyroid disorder

Yes No

frequent ear/throat infection

Yes No

frequent migraine/headache

Yes No

GI disorder/acid reflux

Yes No

heart defect/murmur/disease

Yes No

HIV/AIDS

Yes No

immune system disorder

Yes No

kidney disorder

Yes No

osteoporosis

Yes No

polio/pneumonia/TB

Yes No

seizure/fainting/neurologic disorder

Yes No

skin disorder

Yes No

STDs

Yes No

vision/hearing/speech disorder

Yes No

Please describe any conditions not listed above:

Has the patient reached puberty?

Yes No

Has the patient smoked/vaped?

Yes No

Is the patient allergic to latex?

Yes No

Is the patient currently under the care of a medical professional?

Yes No

Has the patient ever taken bisphosphonate for osteoporosis?

Yes No

Please list all medications (including non-prescription and supplements):

Please list all allergies and sensitivities:

Does your child have a history of the following?

pending dental work

Yes No

injuries to the face/neck/mouth

Yes No

gingivitis/periodontitis

Yes No

nail/cheek/lip biting

Yes No

thumb/finger sucking

Yes No

speech disorder/therapy

Yes No

clenching/grinding

Yes No

clicking/popping/locking of jaw

Yes No

frequent headache/migraine

Yes No

soreness in jaw or face muscles

Yes No

Airway Disorders

removal of tonsils/adenoids

Yes No

mouth breathing

Yes No

snoring/sleep disturbances

Yes No

tiredness/irritation/sleepiness

Yes No

bedwetting

Yes No

Please describe any conditions not listed above:

Date of last dental exam:

Has the patient ever required antibiotics prior to dental treatment?

Yes No

Has the child ever had an orthodontic exam?

Yes No

If yes, where and when:

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

Parent/Guardian Signature:

Relationship to Patient:

Date:

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

Parent/Guardian Signature:

Relationship to Patient:

Date:

PATIENT INFORMATION

PARENT/GUARDIAN INFORMATION

DENTAL INSURANCE INFORMATION

Primary Insurance

Secondary Insurance (if applicable)

Medical History

DENTAL HISTORY

RELEASE AND WAIVER