patient forms

Patient's Name

Nick Name

Age

Date of Birth

Gender

MaleFemale

Height

Weight

School

Grade

Onset of puberty?

yesno

Mother's name

Father's name

Parent is:

SingleMarriedSeparatedDivorcedRemarriedWidowed

Address

Home Phone

Father’s Work

Mother’s Work

Father’s Employer

Mother’s Employer

Person Responsible for this account

His/Her SS#

Address if different from above

Dentist’s Name

Dentist’s Phone

Date of last visit:

Physician’s Name

Physician’s Phone

Dental Insurance Company

Subscriber’s SS#

What concerns about your child’s teeth brought you to our office?

How did you hear about our office?

PLEASE CHECK ANY THAT APPLY:

Medical History

Allergies or asthmaAllergies to latex / metalsHeart MurmurHeart ProblemsRheumatic feverBlood disordersHepatitisLiver or kidney disordersDiabetesCancerNail or lip bitingAIDS antibody positiveSTD’sTonsils removedSpeech problemsMouth breathingPrevious orthodontic care

Dental History

Missing or extra teethGrinding of teethJaw painEarly loss of baby teethThumb or finger suckingTrauma to face or teethNail or lip bitingThumb or finger sucking

Does your child regularly receive any medicine and/or medical treatment?

yesno

If yes, please specify

Has your child ever had an unfavorable reaction to any drugs, antibiotics, or anesthetics?

yesno

If yes, please give details

Other significant physical or mental health considerations (past or present):

Because your child is a minor, it is necessary that a signed permission be obtained from a parent or guardian before any orthodontic services can be started. I have read and understand the above questions. The information provided is accurate to the best of my knowledge. 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. It is my responsibility to notify this practice if there are any changes later to this history record or medical/dental status.

Signature of parent or guardian

Date

Yes, I would like to receive email appointment reminders Email Address

Thank you for your cooperation. The above information is important in your child’s diagnosis and treatment, and will be kept confidential.

Office use: Medical/dental information above reviewed with patient.

Initials

Date

Comments