CHILD PATIENT FORM

PATIENT INFORMATION

Patient name

Male Female

Social security number

Birth date

Age

Home address

City

State

Zip

Primary phone

Home Cell

Email address

School

Grade

Sports/extracurricular activities

Siblings (names and ages)

PARENT/GUARDIAN AND EMERGENCY CONTACT INFORMATION

Parents’ marital status

Single Married Divorced Widowed Significant other

Mother’s name

Birth date

Social security number

Driver’s license number

Address (if different than child’s)

City

State

Zip

Primary phone

Home Cell

Secondary phone

Home Cell Other

Employer

Occupation

Father’s name

Birth date

Social security number

Driver’s license number

Address (if different than child’s)

City

State

Zip

Primary phone

Home Cell

Secondary phone

Home Cell Other

Employer

Occupation

Emergency contact name (other than parent)

Relation

Phone

Address

City

State

Zip

Person(s) OK to release appointment or medically related information to concerning you:

Name

Relation

Name

Relation

INSURANCE INFORMATION

Primary insurance company

Phone

Group number

Policy number

Member ID number

Policy holder’s name

Relation

Policy holder’s social security number

Policy holder’s birth date

Employer

Work phone number

Secondary insurance company

Phone

Group number

Policy number

Member ID number

Policy holder’s name

Relation

Policy holder’s social security number

Policy holder’s birth date

Employer

Work phone number

DENTAL HISTORY

General dentist

Last visit

How did you hear about our practice?

Ad Internet Family or friend Physician Other

Name of person referring (if applicable)

What are the main concerns you would like orthodontics to accomplish?

Has your child visited an orthodontist before?

Yes No

When?

Reason?

Has your child’s tonsils or adenoids been removed?

Yes No

When?

Does your child have any missing or extra permanent teeth?

Yes No

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes No

Has your child ever had an injury to (select all that apply)

Teeth Mouth Chin

Does your child have speech problems?

Yes No

If so, explain

Does your child currently or have they ever had any of the following habits?

Clenching/grinding teeth Nail biting Lip sucking/biting

Thumb/finger sucking Mouth breathing Chewing/eating problems

MEDICAL HISTORY

Is your child currently being treated by a physician?

Yes No

Reason

Physician

Last visit

Phone

Does your child have any allergies/sensitivies to medications or latex?

Yes No

Please list all allergies

Is your child currently taking any prescription or over-the-counter medications?

Yes No

Please list, with dosage

Has puberty and/or menstruation began?

Yes No N/A

Has your child ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes No

Has your child had any operations or serious illnesses? If yes, describe

Has your child ever had a blood transfusion?

Yes No

If yes, give approximate dates:

Is your child pregnant?

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

Check if your child has or has ever had any of the following:

Anemia
Arthritis, Rheumatism
Artificial heart valves
Artificial joints

Asthma
Back problems
Blood disease
Cancer

Chemical dependency
Chemotherapy
Circulatory problems
Cortisone treatments

Cough, persistent
Coughing blood
Diabetes
Epilepsy

Fainting
Glaucoma
Headaches
Heart murmur

Heart problems
Hemophilia
Hepatitis
High blood pressure

HIV/AIDS
Jaw pain
Kidney disease
Liver disease

Mitral valve prolapse
Pacemaker
Radiation treatment
Respiratory disease

Rheumatic fever
Scarlet fever
Shortness of breath
Skin rash

Stroke
Swelling of feet or ankles
Thyroid problems
Tobacco/vaping habit

Tonsillitis
Tuberculosis
Ulcer
Venereal disease

AUTHORIZATION

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient signature and/or responsible party

Date