CHILD PATIENT FORM

PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

Date

Patient’s name

Address

Nickname

Date of Birth

School

Sports/Hobbies

Parent or guardian name

Whom may we thank for referring you to our office?

RESPONSIBLE PARTY INFORMATION

Name

Residence

Mailing Address

Phone

Cell Phone

Email

MEDICAL HISTORY

Physician

Date of Last Visit

Address

Phone

Please circle Yes or No (If Yes, please fill in details)

Is the patient taking any medication?

YesNo

Is the patient allergic to any medication?

YesNo

History of a major illness?

YesNo

Has the patient had any operations?

YesNo

Ever been involved in a serious accident?

YesNo

Have seen a physician in the last 12 months? Why?

YesNo

Does the patient experience sleeping problems such as snoring?

YesNo

Female Patients only:

Has menstruation started?

YesNo

Is the patient pregnant?

YesNo

Circle any of the medical conditions below that the patient has had or currently has.

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY

General Dentist

Date of last visit

What concerns you most about your teeth?

Is the patient presently in any dental pain?

YesNo

Ever experienced any unfavorable reaction to dentistry?

YesNo

Has the patient ever lost or chipped any teeth?

YesNo

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

YesNo

Is any part of your mouth sensitive to temperature? Where?

YesNo

Is any part of your mouth sensitive to pressure? Where?

YesNo

Do gums bleed when brushing?

YesNo

Any type of thumb or tongue habit?

YesNo

Is the patient a mouth breather?

YesNo

Has the patient ever seen an orthodontist? If yes, who and when?

YesNo

What is the patient’s attitude toward receiving orthodontic treatment?

YesNo

Has anyone in the family received orthodontic treatment?

YesNo

How did they feel about the result?

BetterGoodBad

Do teeth or jaws ever feel uncomfortable first thing in the morning?

YesNo

Experience jaw clicking or popping?

YesNo

Experience “tension” headaches?

YesNo

Has the patient ever experienced chronic ringing in the ears?

YesNo

Does the patient need extra help with instructions?

YesNo

Is the patient sensitive or self-conscious about his/her teeth?

YesNo

Height of parents?

YesNo

you aware that some appointments will be during school hours?

YesNo

BENEFITS

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history.