Child Patient Information

First Name:
Last Name:
Home Address:
City:
Province:
Postal Code:
Home Phone:
Sex:
Work Phone:
Birth Date:
Dentist:
Last visit:
School:
Email:
MB Health Number:
Treaty Number:
Family Information
The following information is requested so that we can communicate properly with the people involved with your childs treatment
Parents are:
Child lives with:
Who should receive routine information about treatment progress?
Patients' Mother
Last name:
First Name:
Home Address:
City:
Province:
Postal Code:
Home phone number:
Occupation:
Employer:
Business phone:
Cell phone:
E-mail:
Patients' Father
Last name:
First Name:
Home Address:
City:
Province:
Postal Code:
Home phone number:
Occupation:
Employer:
Business phone:
Cell phone:
E-mail:
Other adults we should know about?
Last Name:
First Name:
Relationship to you?
Phone (H):
Phone (O):
Patient siblings?
Name:
Age:
School:
Name:
Age:
School:
Name:
Age:
School:
Who can we thank for sending you to our office?

Medical Information

Do you have (or have you had) any of the following?
Allergies/sensitivities to medicine
Eye problems
Stomach Problems
Bone disorder
Asthma
Uses Inhaler x/week:
Liver problems/hepatitis
Bleeding disorders/transfusions/anemia
Kidney problems
Heart Problems
Rheumatic fever
Thyroid disorder
HIV/AIDS
Emotional/nervous/psychiatric issues
Smoke
Cigarettes/day:
Sleep Apnea
Tonsillitis
Date removed:
Boys: Has voice changed?
Girls: Has menstruation begun?
Date started:
Describe any other medical issues (medication, illness, surgery) if not listed above:
Physician's name:
Last exam:
How can we help you? To satisfy your concerns, we need to know more about your reasons for visiting our office. Please answer the following questions to the best of your ability.
1. Are you satisfied with the way the teeth look?
If NO, tell us how would you change them? (Try to be specific: upper/lower, front/back teeth should be moved up/down, forward/back...)
2. Do you have any concerns about the bite or the way the teeth fit together?
If YES, please try to tell us what the problem is
3. Do you have any concerns about the facial appearance/profile?
If YES, please tell us if you know what you would like to see changed. (Try to be specific: upper/lower jaw(s) should be moved up/down, forward/back, show less gum when smiling, lips...)
Are you here mainly on the advice of your dentist?
Anything else you would like to discuss?

Dental Background

When was your last check-up/cleaning with the dentist?
How often do you brush/day?
How often do you floss/day?
Has your child:
Had a previous orthodontic consult or previous orthodontic treatment?
When?
Seen a gum specialist, root canal dentist, oral surgeon, or crown/bridge dentist?
What for?
Had any:
When?
Been told you have gum disease or periodontal disease?
Had trouble associated with dental treatment?
Ever injured or broken any teeth?
When and what happened?
Ever injured the head or face?
When and what happened?
Had any teeth extracted?
Why?
Does your child:
Have any missing of extra teeth?
Have any dental/facial pain or headaches?
Frequency?
Times/
Have a jaw joint that makes noises/hurts when opening/closing/chewing?
Grind or clench the teeth together?
Have problems breathing through the nose?
Have any speech difficulties?
Have any problems with eating, chewing, or swallowing?
Are you aware of any swellings or growths in the face or mouth?
Do you have any negative or resistant feelings about orthodontic treatment?
Has any member of your family had orthodontic treatment?
Is there any other information that we should know?

By giving us your email address and signing this form you authorize Dr. Tim Dumore and his staff to use your email address for appointment reminders, contests, financial reasons or anything pertaining to your treatment in this office or with another dentist or specialist. Please note that we do not share email addresses with outside parties.