New Child Patient Information Questionnaire

IMPORTANT: Please fill out this patient questionnaire and bring your insurance card/form (with the employee's sections filled out and signed) to your consultation appointment at our office.

Patient Information

First Name:
Middle Initial:
Last Name:
Nickname (if any):
Birthdate:
Home Phone:
Gender:
Height:
Weight:
Age:
Address:
City:
State:
Zip:
School:
Grade:
Email:
Parents Are:

What is your child's:

Favorite color:
Favorite sport:
Favorite school subject:
What does your child like to do in their spare time (hobbies, sports, recreation)?
Anything else you'd like to tell us about your child:

Referral

Whom may we thank for referring you to our practice?

Siblings

To best serve our families and community, we offer a family program as a courtesy to our patients. We see the young children every 6 months at no charge. This program allows us to keep a record and monitor the growth and development of each child. Please list all siblings of this patient:

Sibling 1
Name:
Birthdate:
Age:
Does he/she have orthodontic problems?
Has he/she been treated for orthodontics?
Sibling 2
Name:
Birthdate:
Age:
Does he/she have orthodontic problems?
Has he/she been treated for orthodontics?
Sibling 3
Name:
Birthdate:
Age:
Does he/she have orthodontic problems?
Has he/she been treated for orthodontics?

Financially Responsible Person(s)

Responsible Party 1

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Previous Address (If less than 3 years at present address)
Relationship to Patient:
Home Phone:
Cell Phone:
Work Phone:
S.S. #:
Birthdate:
Age:
Driver's Lic. #:
Employer:
Occupation:
Length of Employment:

Spouse Information

First Name:
Middle Initial:
Last Name:
Employer:
Cell Phone:

Responsible Party 2

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Previous Address (If less than 3 years at present address)
Relationship to Patient:
Home Phone:
Cell Phone:
Work Phone:
S.S. #:
Birthdate:
Age:
Driver's Lic. #:
Employer:
Occupation:
Length of Employment:

Spouse Information

First Name:
Middle Initial:
Last Name:
Employer:
Cell Phone:

Insurance Information

Insured's Name:
Insurance Company:
Insurance Co. Address:
Subscriber SSN:
Group Number:
Local Number:
Policy Holder's Employer:
Do you have dual dental coverage?
(If yes, complete information below)
Insured's Name:
Insurance Company:
Insurance Co. Address:
Subscriber SSN:
Group Number:
Local Number:

Dental History

Dentist Name:
Dentist Address:
Dentist Phone:
Date Last Checked:
Have there been any injuries to the face, mouth or teeth?
Has the patient ever sucked his/her thumb or fingers?
Has the patient undergone speech therapy?
Are you aware of any missing permanent teeth?
Has the patient received any previous orthodontic treatment?
What is the chief concern regarding your child's teeth?
Does child have or has child had the following:
Thumb sucking
Finger sucking
Nail or lip biting
Pencil biting
Mouth breathing
Tongue thrust
Clenching
Grinding (day or night)
Other
Does child have any of the following:
Teeth sensitive to cold, heat, sweets or pressure?
* Bleeding gums?
If so, how long?
Food impaction
Burning of tongue
Swelling or lumps in mouth
Frequent blisters on lips or mouth
Pain around ear
Unusual sounds while eating
Bad breath
Unpleasant taste
Unfavorable dental experience
Complications from extractions
Periodontal treatment
Bone loss

Do you regularly...

* Brush
Times a day:
Floss daily
Use mouthwash

Medical History

Physician Name:
Physician Phone:
Address:
City:
State:
Zip:
Medical or physical disorders:
Is child in good health:
Taking any medications now:
Is child under the care of a physician's care now? If so, please give reasons for treatments.
Does child experience or has child experienced:
Chest pain (Angina)?
Swollen ankles
Shortness of breath
Recent weight loss fever night sweats
Persistent cough/coughing up blood
Bleeding problems bruising easily
Sinus problems
Difficulty swallowing
Diarrhea, constipation, blood in stools
Frequent vomiting, nausea
Difficulty urinating, blood in urine
Dizziness
Ringing in ears
Headaches
Fainting spells
Pregnancy or nursing (females only)
Blurred vision
Seizures
Excessive thirst
Frequent urination
Dry mouth
Jaundice
Joint pain, stiffness
Do you have or have you had:
Heart disease, heart attack
Heart murmur
Rheumatic fever
Stroke, hardening of arteries
High blood pressure
TB, emphysema, other lung disease
Hepatitis, other liver disease
Nervous disorders
Stomach problems, ulcers
Allergies to drugs, food, medications?
Allergies to latex gloves
Family history of diabetes, heart problems or tumors
AIDS or ARC
Tumors, cancer
Arthritis, Rheumatism
Asthma?
Eye disease
Skin diseases
Anemia or blood disorder?
VD (syphilis or gonorrhea)
Herpes
Kidney, bladder disease?
Thyroid, adrenal disease
Taken Fen-Phen or appetite suppressants
Psychiatric care
Radiation treatments
Chemotherapy
Prosthetic heart valves
Artificial joints?
Hospitalizations
Surgeries
Pacemaker
Contact lenses
Blood transfusions
Do you take:
Drug, medicines (including aspirin and birth control pills)
Bisphosphonates (eg. Fosamax, Boniva, Actonel, Azedia, Reclast, etc.)
Recreational drugs
Tobacco in any form
Alcohol
Does child have or has child had any other diseases or medical problems NOT listed on this form?
Any other information we should know about your child's health?
Signature:
Date: