Health History for Minor/Child

Patient Biographical Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Patient's School:
Grade:
Patient's Cell (if applicable):
Okay to receive text reminders?
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:
Name:
Relationship to Patient:
* Primary Phone:
Phone 2:
Email:
How would you like to receive reminders?

Mother/Father/Guardian 2

Title:
Name:
Relationship to Patient:
Primary Phone:
Phone 2:
Email:
How would you like to receive reminders?

If patient is a girl, has menstruation begun? If yes, when?
If patient is a boy, has his voice changed or have facial hair? If yes, when?
Has the patient grown in the past year or has their shoe size changed recently?
How does the patient feel about having orthodontic treatment?
Has either biological parent ever had orthodontic treatment?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Primary Phone:
Phone 2:
Employer:
Occupation:
Work Phone:

Dental History

Dentist Name:
Last Dental Visit:
Checkup Frequency:
Has the patient had an orthodontic consult or treatment? 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?
Clench or grind teeth?
Injury to face, jaw, teeth, or mouth?
Discomfort from teeth or gums?
Pain, tenderness, or noise in either jaw?
Frequent headaches?
* Oral habits (thumb/finger sucking)?
If so, until what age?
* Other Oral habits (lip/nail biting, etc)?
Neck or shoulder pain?
Mouth breathing?
Snores during sleep?
Requires Antibiotic Premedication for dental procedures?
Missing or extra permanent teeth?
Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
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?
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?
Tuberculosis or lung disease?
Pneumonia?
Liver disease?
Kidney disease?
Heart attack or stroke?
Heart disease?
Heart defect (congenital)?
Heart murmur?
Hemophilia?
High blood pressure or hypertension?
Prolonged bleeding or transfusion?
Anemia or blood disorder?
HIV or AIDS?
Hepatitis?
Tonsils or adenoids removed?
Cancer?
Family history of oral cancer?
Received radiation treatment?
Growth problems?
Endocrine problems?
Hormone therapy?
Latex Allergy
Nervous disorders?
Bone disorders or loss?
Diabetes?
Seizures/epilepsy?
Handicaps or disabilities?
Asthma?
Arthritis?
Treated for emotional problems?
Ever been hospitalized?
Metal Allergy
If any of the above medical questions were answered 'Yes' , please explain:
E-Signature of Parent/Guardian:
Date