Patients Under Age 18

PATIENT

Date

Patient's Last name

First name

Middle initial

I prefer to be called

Hobbies

Activities

Birth date

What sex was the patient assigned on their birth certificate?

MaleFemale

What is the patient’s current gender identification? MaleFemaleOther

What are the patient’s preferred pronouns?

Social Security #

School

Grade

E-mail address(es)

Home address

City

State

Zip code

Home phone

Cell phone

PARENT/GUARDIAN

Custodial parent(s) name(s)

Other, if other, what is the relationship?

Patient lives with (check all that apply)

Parent 1/GuardianParent 2/GuardianParent 3/GuardianParent 4/Guardian

Parent 1/Guardian full name

Occupation

E-mail address

Address (if different)

Cell phone (if different)

Home phone

Work phone

Parent 2/Guardian full name

Occupation

E-mail address

Address (if different)

Cell phone (if different)

Home phone

Work phone

DENTIST

Patient’s Dentist

Address

City

State

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen: Name

Reason

FAMILY MEDICAL HISTORY

Have the parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disorders

Diabetes

Arthritis

Severe allergies

Unusual dental problems

Jaw size imbalance

Other family medical conditions?

MEDICAL HISTORY UPDATES OR CHANGES

Changes

GENERAL INFORMATION

What concerns you about your child’s teeth?

How does your child feel about orthodontic treatment?

Who suggested that your child might need orthodontic treatment?

Why did you select our office?

Describe any previous orthodontic treatment or consultations.

Does your child play a musical instrument?

Sibling name

Age

Had orthodontic treatment?
YesNo

If yes, where?

Have any other family members been treated in this office? Please name them.

DENTAL INSURANCE

Primary policy holder’s full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID#

Does this policy have orthodontic benefits?
Yes.No.Don’t Know.

Secondary policy holder’s full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID#

Does this policy have orthodontic benefits? Yes.No.Don’t Know.

MEDICAL INSURANCE

Policy holder’s full name

Insurance Company

PHYSICIAN

Patient’s Physician

City

State

Last seen

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen now:

Name

City

State

Reason

Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, mark yes, no, or don’t know/understand (dl/u).

PATIENT HEALTH INFORMATION

Does the patient take antibiotic pre-medication before any dental procedures?

YesNo

Does the patient currently have (or ever had) a substance abuse problem?

Do you think that any of your child’s activities affect his/her/their face, teeth or jaws? How?

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.

Medication

Taken for

Medication

Taken for

Medication

Taken for

Does your child chew or smoke tobacco?

Have you noticed any unusual changes in your child’s face or jaws?

Any other physical problems?

RELEASE AND WAIVER

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

Parent/Guardian Signature

Date

Patients Under Age 18

Medical Dental History Form For Patients Under Age 18

PATIENT

PARENT/GUARDIAN

DENTIST

MEDICAL HISTORY continued

Has your child had allergies or reactions to any of the following?

DENTAL HISTORY

Now or in the past, has your child had:

FAMILY MEDICAL HISTORY

MEDICAL HISTORY UPDATES OR CHANGES

GENERAL INFORMATION

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

Other physicians/health care providers being seen now:

Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, mark yes, no, or don’t know/understand (dl/u).

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.

MEDICAL HISTORY

Now or in the past, has your child had:

RELEASE AND WAIVER

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