Medical Dental History Form for Patients Under Age 18

Thank you for taking the time to fill this form out completely. We are excited that you have selected us to provide orthodontic care for your family!

Confidential Patient Information

Whom may we thank for referring you to our office:
In your own words, describe main orthodontic concern:
* First Name:
MI:
* Last Name:
Age:
Prefers to be called:
* Birthdate:
* Sex:
Height:
Weight:
Hobbies:
* Address:
* City:
* State:
* Zip:
How long at this address?
* Home Phone:
Cell Phone:
Email:
Previous Address If Less Than 1 Year:
How Long:
Father/Legal Guardian
Name:
Occupation:
How Long:
Home Address:
Home Phone:
Cell Phone:
Email:
Employer:
Business Phone:
Business Address:
Driver's License:
SS #:
DOB:
Mother/Legal Guardian
Name:
Occupation:
How Long:
Home Address:
Home Phone:
Cell Phone:
Email:
Employer:
Business Phone:
Business Address:
Driver's License:
SS #:
DOB:

Insurance Information

Do you have orthodontic coverage on your dental plan?      (If yes, complete information below)
Insured's Name:
Insured's ID #:
Insurance Company:
Group No.:
Insurance Co. Address:
Insurance Co. Phone No.:
Is policy connected with your union?
Name of Union:
Union Local #:
Do you have Dual Coverage?      (If yes, please complete the following)

Insured's Name:
Insured's ID #:
Insurance Company:
Group No.:
Insurance Co. Address:
Insurance Co. Phone No.:
Is policy connected with your union?
Name of Union:
Union Local #:

General Information

Name of any family member in treatment or previously had treatment with us:
Number of children in family:
Ages
Has patient had previous orthodontic treatment?
If yes, how long ago?
Name of previous orthodontist:
General Dentist Name:
Address:
Phone #:
Date of last dental check-up:
Currently undergoing treatment?
Date when last full mouth x-rays taken:
Physician Name:
Address:
Date of last medical check-up:
Currently undergoing treatment?

Medical History

Is your child in general good health at this time?
FEMALES: Started menstruation?
If yes, how long ago?
Is your child pregnant?
Is your child currently being treated for any medical conditions? If yes, please list.
Is your child taking any drugs or medications? If yes, please list.
Has your child had any adverse response to any drugs, including penicillin? If yes please list.
Is your child allergic to any known materials including latex resulting in hives, asthma, eczema etc? If yes, please list.
Does your child require antibiotic premedication prior to any dental procedure?
Does your child have any history of major illness? If yes, please describe.
Has your child ever been hospitalized? If yes, please describe.
Has your child had any surgical procedures? If yes, please describe.
Now or in the past has your child had: (please check all that apply)

Does your child have unexplained awakenings from sleep?
Does your child stop breathing for short periods during sleep?
Does your child get excessively tired during the day and/or fall asleep when they should be awake?
Is your child on a diet at this time?
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actone(ridenfronate), Boniva (bandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
Has your child ever smoked or used tobacco products?
Does your child have any medical conditions not previously mentioned? If yes, please list.

Dental History

Any History Of:
* Thumb or finger sucking?
If yes, until what age?
* Speech difficulty or speech therapy?
* Do your child’s gums bleed?
* Has your child ever had gum disease, or periodontal treatment?
* Does your child frequently get sore spots in his/her mouth?
* Does your child have any dental complaints at the present time? If yes, please describe.
* Have there been any injuries to the face, mouth, or teeth? If yes, please describe.
* Does your child experience frequent headaches?
* Does your child have a history of back or neck injuries?
* Does your child have any clicking or popping of their jaw (TMJ)?
* Does your child have pain in or around the ears?
* Does any part of his/her mouth hurt when clenched?
* Does your child habitually clench or grind his/her teeth during the night or day?
* Does your child chew on only one side of his/her mouth?
* Does your child have difficulty eating foods?
* Are any parts of your child's mouth sore to pressure or irritants (cold, sweets, etc)?
Does your child have any dental conditions not previously mentioned? If yes, please describe.

Emergency Information

Name:
Phone:
Relationship to Patient:

Purpose of Consent (HIPPA) By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.

CONSENT FOR EXAMINATION & CREDIT REPORT (WHEN REQUIRED) – PARENT/CUSTODIAL PARENT/LEGAL GUARDIAN SIGNATURE REQUIRED:

Parent/Responsible Party Signature:
Date: