Pairorthodontics calabasas child health history form

Have there been any injuries to the face, mouth or teeth?

Yes No

Has your child ever sucked his/her thumb or fingers?

Yes No

Until what age?

Does your child have any speech problems?

Yes No

Is your child a mouth breather?

Yes No

Has your child had tongue-thrust or speech therapy?

Yes No

Have you ever been informed of any missing or extra teeth?

Yes No

Has an orthodontist been consulted previously?

Yes No

Who?

Have you been told your child has TMJ (Temporomandibular Joint) problems?

Yes No

Has your child’s jaw ever locked open?

Yes No

Does your child’s jaw joint ever make noise (cracking or popping sound) when chewing or yawning?

Yes No

WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH?

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my child’s medical status.

Calabasas

ORTHODONTICS ACQUAINTANCE CARD

ABOUT YOUR CHILD

ABOUT YOU

IF YOU HAVE ORTHODONTICS INSURANCE, PLEASE COMPLETE INFORMATION BELOW:

DENTAL INSURANCE COMPANY #1

DENTAL INSURANCE COMPANY #2

This Dental Insurance is provided through:

This Dental Insurance is provided through:

DENTAL/MEDICAL HISTORY

PLEASE CHECK:

DOES YOUR CHILD NEED TO BE PREMEDICATED BEFORE DENTAL TREATMENT?

IS YOUR CHILD ALLERGIC TO ANY DRUGS?

PLEASE CHECK:

WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH?