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Patient Form (Minors)
Patient
Date
Patient’s last name
*
First name
*
Middle initial
Prefers to be called
Hobbies, activities
Birth date
Sex
Male
Female
Social Security #
School
Grade
Email address(es)
Home address
City, State, Zip code
Home phone
Cell phone
Parent/guardian
Custodial parent(s) name(s)
Patient lives with (check all that apply)
Mother
Father
Stepmother
Stepfather
Grandparent(s)
Other
Father’s full name
Title:
Mr
Dr
Occupation
Email address
Address (if different)
Home phone (If different)
Cell phone
Work phone
Mother’s full name
Title:
Mrs
Ms
Dr
Occupation
Email address
Address (if different)
Home Phone (If different)
Cell phone
Work phone
Dentist
Patient’s Dentist
Address, City, State
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen: Name
City, State
Reason
General Information
What concerns you about your child’s teeth?
What concerns your child about his/her 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?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Have any other family members been treated in this office? Please name them.
Financial Responsibility
Who is financially responsible for this account?
Address (if different than page 1)
City, State, Zip
Home phone
Cell phone
Email address(es)
Social Security #
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
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
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, please mark yes, no, or don’t know/understand (dk/u)
Medical History
Now or in the past, has your child had:
Birth defects or hereditary problems?
Yes
No
DK/U
Bone fractures or major injuries?
Yes
No
DK/U
Any injuries to face, head, neck?
Yes
No
DK/U
Arthritis or joint problems?
Yes
No
DK/U
Cancer, tumor, radiation treatment or chemotherapy?
Yes
No
DK/U
Endocrine or thyroid problems?
Yes
No
DK/U
Diabetes or low sugar?
Yes
No
DK/U
Kidney problems?
Yes
No
DK/U
Immune system problems?
Yes
No
DK/U
History of osteoporosis?
Yes
No
DK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Yes
No
DK/U
AIDS or HIV positive?
Yes
No
DK/U
Hepatitis, jaundice, or other liver problems?
Yes
No
DK/U
Polio, mononucleosis, tuberculosis, pneumonia?
Yes
No
DK/U
Seizures, fainting spells, neurologic problems?
Yes
No
DK/U
Mental health disturbance or depression?
Yes
No
DK/U
History of eating disorder (anorexia, bulimia)?
Yes
No
DK/U
Frequent headaches or migraines?
Yes
No
DK/U
High or low blood pressure?
Yes
No
DK/U
Excessive bleeding or bruising, anemia?
Yes
No
DK/U
Chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
DK/U
Heart defects, heart murmur, rheumatic heart disease?
Yes
No
DK/U
Angina, arteriosclerosis, stroke or heart attack?
Yes
No
DK/U
Skin disorder (other than common acne)?
Yes
No
DK/U
Does your child eat a well-balanced diet?
Yes
No
DK/U
Vision, hearing, or speech problems?
Yes
No
DK/U
Frequent ear infections, colds, throat infections?
Yes
No
DK/U
Asthma, sinus problems, hayfever?
Yes
No
DK/U
Tonsil or adenoid condition?
Yes
No
DK/U
Does your child frequently breathe through his/her mouth?
Yes
No
DK/U
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Yes
No
DK/U
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
Yes
No
DK/U
Has your child had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)
Yes
No
DK/U
Latex (gloves, balloons)
Yes
No
DK/U
Aspirin
Yes
No
DK/U
Ibuprofen (Motrin, Advil)
Yes
No
DK/U
Penicillin
Yes
No
DK/U
Other antibiotics
Yes
No
DK/U
Metals (jewelry, clothing snaps)
Yes
No
DK/U
Acrylics
Yes
No
DK/U
Plant pollens
Yes
No
DK/U
Animals
Yes
No
DK/U
Foods
Yes
No
DK/U
Other substances
Yes
No
DK/U
Other substances
Dental History
Now or in the past, has your child had:
Erupting teeth very early or very late?
Yes
No
DK/U
Primary (baby) teeth removed that were not loose?
Yes
No
DK/U
Permanent or extra (supernumerary) teeth removed?
Yes
No
DK/U
Supernumerary (extra) or congenitally missing teeth?
Yes
No
DK/U
Chipped or injured primary or permanent teeth?
Yes
No
DK/U
Any sensitive or sore teeth?
Yes
No
DK/U
Any lost or broken fillings?
Yes
No
DK/U
Jaw fractures, cysts, infections?
Yes
No
DK/U
Any teeth treated with root canals or pulpotomies?
Yes
No
DK/U
Frequent canker sores or cold sores?
Yes
No
DK/U
History of speech problems or speech therapy?
Yes
No
DK/U
Difficulty breathing through nose?
Yes
No
DK/U
Mouth breathing habit or snoring at night?
Yes
No
DK/U
History of speech problems?
Yes
No
DK/U
Frequent oral habits (sucking finger, chewing pen, etc)?
Yes
No
DK/U
Teeth causing irritation to lip, cheek or gums?
Yes
No
DK/U
Tooth grinding or clenching?
Yes
No
DK/U
Clicking, locking in jaw joints?
Yes
No
DK/U
Soreness in jaw muscles or face muscles?
Yes
No
DK/U
Has your child been treated for “TMJ” or “TMD” problems?
Yes
No
DK/U
Any broken or missing fillings?
Yes
No
DK/U
Any serious trouble associated with previous dental treatment?
Yes
No
DK/U
Has your child ever been diagnosed with gum disease or pyorrhea?
Yes
No
DK/U
Patient Health Information
Do you think that any of your child’s activities affect his/her 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 take antibiotic pre-medication before any dental procedures?
Does your child have (or ever had) a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child’s face or jaws?
Any other physical problems?
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?
How often does your child brush?
Floss?
Release and Waiver
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.
Parent/Guardian Signature
Date
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
Medical History Updates or Changes
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:
Patient
Date
Patient’s last name
*
First name
*
Middle initial
Prefers to be called
Hobbies, activities
Birth date
Sex
Male
Female
Social Security #
School
Grade
Email address(es)
Home address
City, State, Zip code
Home phone
Cell phone
Parent/guardian
Custodial parent(s) name(s)
Patient lives with (check all that apply)
Mother
Father
Stepmother
Stepfather
Grandparent(s)
Other
Father’s full name
Title:
Mr
Dr
Occupation
Email address
Address (if different)
Home phone (If different)
Cell phone
Work phone
Mother’s full name
Title:
Mrs
Ms
Dr
Occupation
Email address
Address (if different)
Home Phone (If different)
Cell phone
Work phone
Dentist
Patient’s Dentist
Address, City, State
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen: Name
City, State
Reason
General Information
What concerns you about your child’s teeth?
What concerns your child about his/her 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?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Brother/sister name
age
had orthodontic treatment?
Yes
No
If yes, where?
Have any other family members been treated in this office? Please name them.
Financial Responsibility
Who is financially responsible for this account?
Address (if different than page 1)
City, State, Zip
Home phone
Cell phone
Email address(es)
Social Security #
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
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
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, please mark yes, no, or don’t know/understand (dk/u)
Medical History
Now or in the past, has your child had:
Birth defects or hereditary problems?
Yes
No
DK/U
Bone fractures or major injuries?
Yes
No
DK/U
Any injuries to face, head, neck?
Yes
No
DK/U
Arthritis or joint problems?
Yes
No
DK/U
Cancer, tumor, radiation treatment or chemotherapy?
Yes
No
DK/U
Endocrine or thyroid problems?
Yes
No
DK/U
Diabetes or low sugar?
Yes
No
DK/U
Kidney problems?
Yes
No
DK/U
Immune system problems?
Yes
No
DK/U
History of osteoporosis?
Yes
No
DK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Yes
No
DK/U
AIDS or HIV positive?
Yes
No
DK/U
Hepatitis, jaundice, or other liver problems?
Yes
No
DK/U
Polio, mononucleosis, tuberculosis, pneumonia?
Yes
No
DK/U
Seizures, fainting spells, neurologic problems?
Yes
No
DK/U
Mental health disturbance or depression?
Yes
No
DK/U
History of eating disorder (anorexia, bulimia)?
Yes
No
DK/U
Frequent headaches or migraines?
Yes
No
DK/U
High or low blood pressure?
Yes
No
DK/U
Excessive bleeding or bruising, anemia?
Yes
No
DK/U
Chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
DK/U
Heart defects, heart murmur, rheumatic heart disease?
Yes
No
DK/U
Angina, arteriosclerosis, stroke or heart attack?
Yes
No
DK/U
Skin disorder (other than common acne)?
Yes
No
DK/U
Does your child eat a well-balanced diet?
Yes
No
DK/U
Vision, hearing, or speech problems?
Yes
No
DK/U
Frequent ear infections, colds, throat infections?
Yes
No
DK/U
Asthma, sinus problems, hayfever?
Yes
No
DK/U
Tonsil or adenoid condition?
Yes
No
DK/U
Does your child frequently breathe through his/her mouth?
Yes
No
DK/U
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Yes
No
DK/U
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
Yes
No
DK/U
Has your child had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)
Yes
No
DK/U
Latex (gloves, balloons)
Yes
No
DK/U
Aspirin
Yes
No
DK/U
Ibuprofen (Motrin, Advil)
Yes
No
DK/U
Penicillin
Yes
No
DK/U
Other antibiotics
Yes
No
DK/U
Metals (jewelry, clothing snaps)
Yes
No
DK/U
Acrylics
Yes
No
DK/U
Plant pollens
Yes
No
DK/U
Animals
Yes
No
DK/U
Foods
Yes
No
DK/U
Other substances
Yes
No
DK/U
Other substances
Dental History
Now or in the past, has your child had:
Erupting teeth very early or very late?
Yes
No
DK/U
Primary (baby) teeth removed that were not loose?
Yes
No
DK/U
Permanent or extra (supernumerary) teeth removed?
Yes
No
DK/U
Supernumerary (extra) or congenitally missing teeth?
Yes
No
DK/U
Chipped or injured primary or permanent teeth?
Yes
No
DK/U
Any sensitive or sore teeth?
Yes
No
DK/U
Any lost or broken fillings?
Yes
No
DK/U
Jaw fractures, cysts, infections?
Yes
No
DK/U
Any teeth treated with root canals or pulpotomies?
Yes
No
DK/U
Frequent canker sores or cold sores?
Yes
No
DK/U
History of speech problems or speech therapy?
Yes
No
DK/U
Difficulty breathing through nose?
Yes
No
DK/U
Mouth breathing habit or snoring at night?
Yes
No
DK/U
History of speech problems?
Yes
No
DK/U
Frequent oral habits (sucking finger, chewing pen, etc)?
Yes
No
DK/U
Teeth causing irritation to lip, cheek or gums?
Yes
No
DK/U
Tooth grinding or clenching?
Yes
No
DK/U
Clicking, locking in jaw joints?
Yes
No
DK/U
Soreness in jaw muscles or face muscles?
Yes
No
DK/U
Has your child been treated for “TMJ” or “TMD” problems?
Yes
No
DK/U
Any broken or missing fillings?
Yes
No
DK/U
Any serious trouble associated with previous dental treatment?
Yes
No
DK/U
Has your child ever been diagnosed with gum disease or pyorrhea?
Yes
No
DK/U
Patient Health Information
Do you think that any of your child’s activities affect his/her 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 take antibiotic pre-medication before any dental procedures?
Does your child have (or ever had) a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child’s face or jaws?
Any other physical problems?
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?
How often does your child brush?
Floss?
Release and Waiver
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.
Parent/Guardian Signature
Date
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
Medical History Updates or Changes
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:
