CHILD PATIENT INFORMATION
Personal Information
Patient First Name:
Middle Initial:
Last Name:
Nickname:
Address:
City:
State:
Zip:
Home Phone:
Birthdate:
Age:
School:
Hobbies & Interests:
Gender:
Male
Female
Other
To whom can we thank for referring you to our office?
Parent's Information
FATHER
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Phone:
Cell Phone:
Email:
Employer:
Occupation:
Work Phone:
Employer Address:
City:
State:
Zip:
MOTHER
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Phone:
Cell Phone:
Email:
Employer:
Occupation:
Work Phone:
Employer Address:
City:
State:
Zip:
Responsible Party Information
Person Financially Responsible
First Name:
Middle Initial:
Last Name:
Date of Birth:
Phone:
Social Security Number:
Employer:
Occupation:
Employer Address:
Employer Phone:
With whom does the patient reside? (Please provide the name.)
Legal Guardian:
Mother:
Father:
Both Parents:
Self:
Do you have dental insurance?
No
Yes
Insurance Information
Primary Dental Insurance Information
Patients' Relationship To Subscriber:
Full Legal Name of Insured Subscriber:
Date of Birth:
Social Security Number:
Insurance Company Information
Insurance Company Name:
Group Number:
Identification Number:
Address of Insurance Company:
City:
State:
Zip:
Phone Number of Insurance Company:
Secondary Dental Insurance Information
Patients' Relationship To Subscriber:
Full Legal Name of Insured Subscriber:
Date of Birth:
Social Security Number:
Insurance Company Information
Insurance Company Name:
Group Number:
Identification Number:
Address of Insurance Company:
City:
State:
Zip:
Phone Number of Insurance Company:
Medical History
Dentist Name:
Physician Name:
Latex Allergy?
No
Yes
Anemia?
No
Yes
Diabetes?
No
Yes
Fainting/Dizziness?
No
Yes
Hepatitis?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Liver Involvement?
No
Yes
Asthma?
No
Yes
Endocrine problems?
No
Yes
Glaucoma?
No
Yes
HIV or AIDS?
No
Yes
Nervous disorders?
No
Yes
Rheumatic fever?
No
Yes
Bone disorders?
No
Yes
Epilepsy?
No
Yes
Heart trouble?
No
Yes
Kidney Involvement?
No
Yes
Pneumonia?
No
Yes
Tuberculosis?
No
Yes
Have tonsils and adenoids been removed?
No
Yes
Has the patient ever smoked, vaped, or chewed tobacco?
No
Yes
List any drugs or medications now being taken. Give Reasons:
History of allergies or drug sensitivity (specify):
Female Patients Only:
Has menstruation started?
No
Yes
Is patient pregnant?
No
Yes
Dental History
Have there been any injuries to the face, mouth, or teeth?
No
Yes
Does the patient have any speech problems?
No
Yes
Have you been informed of any missing or extra permanent teeth?
No
Yes
Has an orthodontist been consulted previously?
No
Yes
Has the patient been diagnosed with sleep apnea?
No
Yes
Any type of thumb or tongue habit?
No
Yes
Is the patient a mouth breather?
No
Yes
Do teeth or jaws ever feel uncomfortable first thing in the morning?
No
Yes
Experience jaw clicking or popping?
No
Yes
Aware of clenching or grinding teeth during the day?
No
Yes
Experience 'tension' headaches?
No
Yes
Has the patient ever experience chronic ringing in the ears?
No
Yes
Does the patient need extra help with instructions?
No
Yes
Is the patient self-conscience about his/her teeth?
No
Yes
Are you aware that some appointments will be required during school hours?
No
Yes
Height of parents:
Mom:
Dad:
Has the patient ever seen an orthodontist?
No
Yes
If yes, who and when?
Has anyone in the family received orthodontic treatment?
No
Yes
How did they feel about the result?
What is the patient's attitude toward receiving orthodontic treatment?
Please list any fears or disabilities so we can help make your appointments more comfortable.
What are you most interested in today?
Braces
Clear Aligners
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth. in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases Teeth change throughout our lifetime and here can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Marshall to perform a complete orthodontic evaluation.
Signature:
Date: