CHILD/ADOLESCENT PATIENT INFORMATION FORM
TELL US ABOUT YOU:
Last First MI
Who is accompanying you today?

Other family members seen by us:

MOTHER'S INFORMATION:
FATHER'S INFORMATION:
PERSON RESPONSIBLE FOR ACCOUNT:

  CIRCLE ONE:   CIRCLE ONE
Have you ever been evaluated or had orthodontic treatment before?
Have there been any injuries to your face, mouth, teeth or chin?
Have you been informed of any missing or extra permanent teeth?
Do you currently feel healthy?
Do you still have your wisdom teeth?
Do you need to be premedicated before dental work?
Have you experienced problems with previous dental work?
Are you taking fluoride supplements?
Have you ever had any pain / tenderness in your jaw joint (TMJ/TMD)?
Have adenoids or tonsils been removed?
Has your jaw ever clicked, popped or locked?
Are Immunizations current?
Do you brush your teeth daily?
Boys: Has puberty begun?
Do you floss your teeth daily?
Has your voice changed?
Do your gums bleed?
Girls: Has puberty begun?
Do you play any musical instruments?
Do you take birth control pills?
Are you pregnant?
Are you Allergic
to any of
the following?
Do you now have or have you had any of the following habits? Do you now have or
have you had any of
the following?

Please list any other Allergies that you have:

Please list any other Habits that you have:

Please fill out the insurance section only if you have ORTHODONTIC insurance.

Our office is committed to meeting or exceeding the standards of infection control
mandated by OSHA, the CDC and the ADA.
We reserve the right to verify the credit status prior to extending credit for treatment.
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein.