Keith J. Kohrs, DDS, PC

Specialist in Orthodontics

CHILD HEALTH HISTORY

Patient Information

First Name:
Middle Initial:
Last Name:
Prefers to be called:
Address:
City:
State:
Zip:
Gender:
Age:
Birthdate:
School:
Grade:
Patient Cell (for appointment text reminders):

Responsible Party Information

Primary Responsible Party

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address (if different):
City:
State:
Zip:
How long at this address?
Birthdate:
Cell Phone:
Work Phone:
Home Phone:
Email Address(es):
Occupation:
Employer:
Years with Current Employer:

Secondary Responsible Party

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address (if different):
City:
State:
Zip:
How long at this address?
Birthdate:
Cell Phone:
Work Phone:
Home Phone:
Email Address(es):
Occupation:
Employer:
Years with Current Employer:

Dental Insurance and Financial Information

Primary Policy Holder's Name:
Date of Birth:
Insurance Company Name:
Insurance Phone Number:
Primary Policy Holder's ID or SS#:
Group Number:
Do you have an HSA (health savings account) or Flex account?
Dual insurance info, if applicable:

General Information

Who may we thank for referring you to our practice?
General Dentist:
Last Dental Visit:
Next Dental Visit:
Other Dentists/Specialists now being seen:
Reason:
List your concerns and what you would like to accomplish with orthodontics. Please be specific.
Who suggested that you might need orthodontic treatment?
Has the patient ever been evaluated for orthodontic treatment?
If so, when?
By whom?
How does the patient feel about braces?
How does the patient feel about Invisalign?

Medical and Dental History

Your answers are for office records only, and are confidential. A thorough medical history is essential to complete an orthodontic evaluation. For the following questions, please mark yes, no, or don't know/understand. Now or in the past, have you had or been treated for:

MEDICAL

Birth defects or hereditary problems?
Injury to face, head, or neck?
Arthritis or joint problems?
Cancer, tumor, radiation, or chemotherapy?
Diabetes or low blood sugar?
Kidney problems?
AIDS or HIV positive?
Immune system problems?
Treatment of osteoporosis?
ADD/ADHD?
Hepatitis, jaundice, or other liver problems?
Seizures, fainting spells, or neurological problems?
Mental health disturbance or depression?
Eating disorders (anorexia, bulimia)?
Heart defects?
High or low blood pressure?
Vision, hearing, or speech problems?

DENTAL

Teeth erupting very slow, or very late?
Baby teeth removed that were not loose?
Extra or missing teeth?
Chipped or injured baby or permanent teeth?
Sensitive or sore teeth?
Jaw fractures, cysts, or infections?
Frequent oral habits (thumb sucking, pen chewing)?
History of speech problems or therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Trouble associated with previous dental treatment?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Soreness of jaw muscles or face muscles?
Clicking, locking of jaw joint(s)?
Diagnosis or treatment for TMJ or TMD?
Sleep Apnea?
Other conditions/diseases not listed:
Please list any allergies the patient has:
Please list any medications the patient takes:
Reason:
Please elaborate on any dental or orthodontic concerns and any additional medical concerns:
If female, has menstruation began?
If male, has voice changed or is facial hair present?

Family Information

Sibling Names and Birthdates:
Has anyone in the family had orthodontic treatment?
If so, when?
By whom?
E-Signature:
Date: