FORMULARIOS DEL PACIENTE

Tómese un minuto para imprimir y completar el formulario de información del paciente antes de su primera cita:

FORMULARIO DE HISTORIA MÉDICA DEL NIÑO

FORMULARIO DE HISTORIA MÉDICA PARA ADULTOS

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FORMULARIO DE HISTORIA MÉDICA
PARA PACIENTES MENORES DE 18 AÑOS

(Disponible solo en inglés por el momento)

    Gender

    MaleFemale

    Onset of puberty?

    yesno

    Parent is:

    SingleMarriedSeparatedDivorcedRemarriedWidowed

    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

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


    yesno

    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.


    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.