New Child Patient Intake
Health History Form
Please enter the child's information.
Name
First Name
Last Name
Patient's Nickname
Birth Date
Social security number:
Gender:
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email:
example@example.com
Preferred contact method:
Mobile Phone
Home Phone
Work Phone
Email
School:
Grade:
List any sports or extracurricular activities:
Siblings (names and ages):
Name
Age
1
Name
Age
2
Name
Age
Parent Information:
Parent/guardian name:
Relationship:
Parents' marital status:
Single
Married
Domestic Partner
Separated
Divorced
Widowed
Social security number:
Birth date:
Date
Driver's license number:
Phone number:
Please enter a valid phone number.
Phone type:
Cell
Home
Work
Parent/guardian address (if different than child's):
Apt/Unit #:
Employer's name:
Occupation:
Emergency Contact Information:
Emergency contact name:
Relationship to patient:
Emergency contact number:
Please enter a valid phone number.
Apt./Unit #:
Emergency contact address:
Person(s) OK to release appointment or medically related information to concerning child:
Name
Relationship
1
Name
Relationship
2
Name
Relationship
Primary Care Practitioner
Name:
Phone:
Primary Insurance Information:
Primary insurance company:
Phone:
Please enter a valid phone number.
Group number:
Policy number:
Policy holder's name:
Relationship:
Date of birth:
Date
Employer:
Work phone number:
Please enter a valid phone number.
Social security number:
Co-pay (if known):
Deductible (if known):Co-pay (if known):
Would you like to add Secondary Insurance?
Yes
No
Secondary Insurance Information:
Secondary insurance company:
Phone:
Please enter a valid phone number.
Group number:
Policy number:
Policy holder's name:
Relationship:
Date of birth:
Date
Employer:
Work phone number:
Please enter a valid phone number.
Social security number:
Co-pay (if known):
Deductible (if known):Co-pay (if known):
General dentist name:
Last visit:
How did you hear about our practice?
Internet
Family/friend
Dentist
Ad
Other
Who referred you (if applicable)?
What are the main concerns/goals you would like orthodontics to address/accomplish?
Has your child visited an orthodontist before?
Yes
No
If so, when and for what reason?
Have we treated any other family members? (If so, please list names.)
Yes
No
If Yes, please explain:
Have your child's tonsils or adenoids been removed?
Yes
No
If Yes, please explain:
Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Yes
No
If Yes, please explain:
Does your child have any missing or extra permanent teeth?
Yes
No
If Yes, please explain:
Does your child have speech problems?
Yes
No
If Yes, please explain:
Do your child's gums bleed?
Yes
No
If Yes, please explain:
Does your child smoke? (state #/day)
Yes
No
If Yes, please explain:
Does your child like his/her smile (If no, please explain)
Yes
No
If Yes, please explain:
Has your child ever had an injury to (select all that apply):
Teeth
Mouth
Chin
None
Please explain any injury noted above:
Does your child currently or have they ever had any of the following habits (check all that apply)
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem
Is your child currently being treated by a physician?
Yes
No
If your child is currently being treated by a physician:
Reason:
Physician name:
Date of last visit:
Physician phone:
Please enter a valid phone number.
Does your child have any allergies/sensitivities to medications or latex?
Yes
No
If yes, please list: Any other know allergies
Please list all allergies
Is your child currently taking any prescription or over-the-counter medications?
Yes
No
Please list any Prescription or over the counter medications your child is taking:
Medication Name
Dosage
Reason for Taking?
1
Medication Name
Dosage
Reason for Taking?
2
Medication Name
Dosage
Reason for Taking?
3
Medication Name
Dosage
Reason for Taking?
4
Medication Name
Dosage
Reason for Taking?
5
Medication Name
Dosage
Reason for Taking?
Has puberty and/or menstruation begun?
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 lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin(fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Has your child had any serious illnesses or operations?
Yes
No
Please list any serious illnesses or operations:
Has your child ever had a blood transfusion?
Yes
No
If yes, give approximate dates:
Date
Is your child:
Pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control?
Yes
No
Check if your child has or has ever had any of the following:
Anemia
Artificial joints
Blood disease
Chemotherapy
Cough, persistent
Epilepsy
Heart murmur
Hepatitis
Jaw pain
Mitral valve prolapse
Respiratory disease
Arthritis, Rheumatism
Asthma
Cancer
Circulatory problems
Coughing blood
Glaucoma
Heart problems
High blood pressure
Kidney disease
Pacemaker
Rheumatic fever
Artificial heart valves
Back problems
Chemical dependency
Cortisone treatments
Diabetes
Headaches
Hemophilia
HIV/AIDS
Liver disease
Kidney Involvement
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. 35.
Signature
Parent/Guardian Signature
Date:
Date