Child Health History Form

First Name:
Middle Initial:
Last Name:
Nickname:
Address:
City:
State:
Zip:
Cell Phone:
Gender:
Birthdate:
School:
Grade:
Family Dentist:
Last Dental Visit:
Whom may we thank for referring you to our office?
Have you or any other family members been treated by our office? If so, who?
Reason for seeking orthodontic consultation?
Have you ever been seen by another orthodontist? If so, by whom and when?

Responsible Party Information

Parent/Guardian #1
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Social Security Number:
Employer:
Work Phone:

Parent/Guardian #2
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Social Security Number:
Employer:
Work Phone:

Dental Insurance Information

Policy Holder's Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's SSN:
Policy Holder's DOB:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's SSN:
Policy Holder's DOB:

Medical History

Any Personal History of:
AIDS/HIV +?
Allergy to Latex?
Allergy to Nickel?
Anemia or blood disorder?
Arthritis, Rheumatism?
Artificial Bones/Joints/Valves?
Asthma, Hay Fever?
Bleeding Problems?
Diabetes?
Epilepsy or Convulsions?
Fainting Spells, Seizures?
Heart murmur?
Heart Trouble?
Hepatitis?
High or Low Blood Pressure?
Kidney or Liver Involvement?
Psychiatric Problems?
Rheumatic Fever?
Tuberculosis or lung disease?
Venereal Disease?
Female Patients Only: Are you pregnant now?
Female Patients Only: Has menstruation started?

History of hospitalization? If so, please explain.
Physician Name:
Please list any prescription/over-the-counter medications that your child is taking:
Allergies, sensitivities or reactions to any medications?
Has your child ever had to take antibiotics before dental treatment?
Does your child have any disease, condition, or problem not listed above?

Dental History

Oral Habits History:
Clenching/Grinding Teeth?
Finger/Thumb Sucking?
Lip/Tongue Biting?
Mouth breathing?
Nail Biting?
Smoke or Chew Tobacco?

Any prior accidents to the mouth or teeth? If so, please explain.
Have tonsils and adenoids been removed? If so, please explain.
Does your child now have, or ever had, any TMJ/jaw joint problems, such as popping, clicking, locking or pain? If so, please explain.
I have read and understand the above questions and affirm this information to be accurate. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
Signature:
*By typing my name above I am electronically signing this form.