Patient-Informatiion-Form-Health-Information

What are the main concerns that you would like orthodontics to accomplish?

Has your child ever had any of the following medical problem?

Has your child ever been evaluated or had orthodontic treatment before?

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

List any instruments played:

Have adenoids or tonsils been removed?

Has your child been informed of any missing or extra permanent teeth?

Has your child ever had any pain/tenderness in his/her jaw joint? TMJ/TMD?

Does your child brush his/her teeth daily?

Does your child floss his/her teeth daily?

Child's Physician:

Phone #:

Date of last visit:

Is your child currently under the care of a physician?

Type of treatment is dependent on growth and development, therefore:

Has puberty begun?

Has menstruation begun? (Girls)

Please describe your child's current physical health:

Please list all drugs your child is currently taking:

Please list all drugs that your child is allergic to:

I understand that the information that I have given is correct to the best of my

I authorize the dental staff to perform the necessary dental services

knowledge, that it will be held in the strictest of confidence and it is my

my child may need

responsibility to inform this office of any changes in my child's medical status.

_____________________________________________________

Name of parent or guardian

Date

This office reserves the right to verify the credit status of potential patients

and/or parents prior to extending credit for treatment fees and may, at the

______________________________________________________

discretion of this office, use the services of one or more credit reporting services.

Name of parent or guardian

Date

Abnormal Bleeding

Allergies to any Drugs

Allergies to Latex/Metals

Allergies to Plastic

Any Hospital Stays

Any Operations

Asthma

Cancer

Congenital Heart Defect

Convulsions/Epilepsy

Diabetes

Handicaps/Disabilities

Hearing Impairment

Heart Murmur

Hemophilia

Hepatitis

HIV+/AIDS

Kidney/Liver Problems

Rheumatic/Scarlet Fever

Tuberculosis (TB)

Please discuss any medical problems your child has had:

Does your child have any of the following habits?

Clenching/Grinding Teeth

Lip Sucking/Biting

Mouth Breather

Nail Biting

Nursing/ Bottle Habits

Speech Problems

Thumb/Finger Sucking

Tongue Thrust

Our office is committed to meeting the standards of infection control mandated by OSHA, the CDC and the ADA