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: