Health History for Minor/Child
Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Patient's School:
Grade:
Patient's Cell (if applicable):
Okay to receive text reminders?
Yes
No
Patient's Email (if applicable):
Please list the names of any friends or family currently in the practice?
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Please list the name and birth date of any siblings:
Mother/Father/Guardian 1
Title:
Mr.
Ms.
Mrs.
Dr.
Prof.
Name:
Relationship to Patient:
*
Primary Phone:
Home
Cell
Work
Phone 2:
Home
Cell
Work
Email:
How would you like to receive reminders?
Email
Text
Both
None
Mother/Father/Guardian 2
Title:
Mr.
Ms.
Mrs.
Dr.
Prof.
Name:
Relationship to Patient:
Primary Phone:
Home
Cell
Work
Phone 2:
Home
Cell
Work
Email:
How would you like to receive reminders?
Email
Text
Both
None
If patient is a girl, has menstruation begun?
No
Yes
If yes, when?
If patient is a boy, has his voice changed or have facial hair?
No
Yes
If yes, when?
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
How does the patient feel about having orthodontic treatment?
Has either biological parent ever had orthodontic treatment?
Don't know
No
Yes
Financial Party Information
Check if Guardian 1 (above) will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Primary Phone:
Phone 2:
Employer:
Occupation:
Work Phone:
Dental History
Dentist Name:
Last Dental Visit:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patient's main orthodontic concern?
Any other patient or family concerns?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems or therapy?
No
Yes
Clench or grind teeth?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
*
Oral habits (thumb/finger sucking)?
No
Yes
If so, until what age?
*
Other Oral habits (lip/nail biting, etc)?
No
Yes
Neck or shoulder pain?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires Antibiotic Premedication for dental procedures?
No
Yes
Missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Physician's Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient:
Please list any food or drug allergies/sensitivities that the patient may have:
*
Is the patient adopted?
No
Yes
If yes, at what age?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Rheumatic fever?
No
Yes
Tuberculosis or lung disease?
No
Yes
Pneumonia?
No
Yes
Liver disease?
No
Yes
Kidney disease?
No
Yes
Heart attack or stroke?
No
Yes
Heart disease?
No
Yes
Heart defect (congenital)?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
High blood pressure or hypertension?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Anemia or blood disorder?
No
Yes
HIV or AIDS?
No
Yes
Hepatitis?
No
Yes
Tonsils or adenoids removed?
No
Yes
Cancer?
No
Yes
Family history of oral cancer?
No
Yes
Received radiation treatment?
No
Yes
Growth problems?
No
Yes
Endocrine problems?
No
Yes
Hormone therapy?
No
Yes
Latex Allergy
No
Yes
Nervous disorders?
No
Yes
Bone disorders or loss?
No
Yes
Diabetes?
No
Yes
Seizures/epilepsy?
No
Yes
Handicaps or disabilities?
No
Yes
Asthma?
No
Yes
Arthritis?
No
Yes
Treated for emotional problems?
No
Yes
Ever been hospitalized?
No
Yes
Metal Allergy
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
E-Signature of Parent/Guardian:
Date