CHILD ORTHODONTIC ACQUAINTANCE FORM

DATE BIRTH DATE AGE SEX

PATIENT NAME SCHOOL LEVEL HOME PHONE
ADDRESS CITY STATE ZIP
CONTACT CELL PHONE CELL PHONE CARRIER CONTACT EMAIL

I REQUEST APPOINTMENT REMINDERS VIA: EMAIL TEXT BOTH NONE

FATHER'S NAME ADDRESS (if Different) OCCUPATION/EMPLOYER
CELL PHONE NUMBER CITY STATE ZIP
MOTHER'S NAME ADDRESS (if Different) OCCUPATION/EMPLOYER
CELL PHONE NUMBER CITY STATE ZIP


REFERRED BY FAMILY DENTIST

INSURANCE INFORMATION
DOES THE PATIENT HAVE INSURANCE COVERAGE FOR ORTHODONTIC TREATMENT? YES NO
EMPLOYEE NAME ID NUMBER BIRTHDAY
INSURANCE COMPANY #1 EMPLOYER GROUP NUMBER
EMPLOYEE NAME ID NUMBER BIRTHDAY
INSURANCE COMPANY#2 EMPLOYER GROUP NUMBER

HEALTH QUESTIONNAIRE
The following information is requested to enable us to give the patient the best consideration of their orthodontic problem during the initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

PHYSICIAN NAME BUSINESS ADDRESS
PHONE NUMBER CITY STATE ZIP

Presently under physician's care during the past two years other than routine exams? YES NO
If YES please specify:

Presently taking any medications? YES NO
If YES please list:

Congenital anomalies (birth defects)? YES NO
If YES please specify:

Has the patient had a history of any of the following?
ASTHMA CARDIOVASCULAR DISEASE CANCER HAY FEVER
HEART MURMUR HERPES SINUS PROBLEMS RHEUMATIC FEVER
TUMOR OR GROWTH RESPIRATORY PROBLEMS BLOOD DISEASE SEXUALLY TRANSMITTED DISEASE
TONSILLITIS BONE DISORDER EMOTIONAL PROBLEMS DIZZINESS
AIDS OR HIV POSITIVE EXCESSIVE BLEEDING CONVULSIONS IMMUNE SYSTEM PROBLEMS
FAINTING EPILEPSY INFECTIOUS DISEASE HEPATITIS OR LIVER DISEASE
DIABETES ARTHRITIS OR PAINFUL JOINTS ALCOHOLISM HEARING DISORDER
MIGRAINE HEADACHES DRUG ABUSE AUTISM ADD OR ADHD
OTHER
OTHER Conditions not listed:
Comments:

Has the patient had any serious illness, operation, or been hospitalized within the past 5 years? YES NO
If so, what was the illness or problem?

Respiratory History: Does the patient:
1. Have allergies to:
Seasonal Grasses YES NO
Foods YES NO If YES, specify:
Medications YES NO If YES, specify:
Other YES NO If YES, specify:

2. Snore when sleeping? Seldom Sometimes Often
3. Breathe through mouth? Seldom Sometimes Often
4. Have frequent colds? Seldom Sometimes Often
5. Have frequent stuffy nose? Seldom Sometimes Often
6. Have frequent sore throat or tonsillitis? Seldom Sometimes Often
7. Have chewing or swallowing difficulty? Seldom Sometimes Often
8. Have frequent ear infections? Seldom Sometimes Often

Has the patient recieved medical treatment from an allergist or ear, nose and throat specialist? YES NO
If YES, please specify:
WHEN: BY WHOM: FOR WHAT CONDITION

Has the patient had their adenoids removed? YES NO Has the patient had their tonsils removed? YES NO

Has the patient received or been requested to receive speech correction? YES NO
Does the patient have pain or clicking in the jaw joints? YES NO
If YES please specify:
Does the patient have frequent headaches? YES NO
If YES please specify:
Have any teeth been injured due to accidents or blows to the mouth? YES NO
If YES please specify:

Please provide information as it pertains to the patient regarding the following habits:
Thumb sucking until age Finger sucking until age
Grinding of teeth YES NO Pacifier until age
Nail biting YES NO Smoking YES NO
Lip biting or sucking YES NO Tongue thrusting YES NO
Other:

Has the patient had any unusual dental experiences? YES NO
If YES please specify:
Date of last dental cleaning:

Has the patient had any previous orthodontic consultations? YES NO Or treatment? YES NO
Date: Doctor:

Orthodontic consultation prompted by Patient Dentist Physician Mother Father Sibling
Patient's Interest in orthodontic treatment Eager Indifferent Resigned Opposed to treatment
What do you feel is the primary problem?
Have any family members been examined or treated in our office? YES NO
If YES please specify:

Growth Information:
1. Has the patient shown signs of increased growth recently? YES NO
2. Patient's estimated present height?
3. Father's present height? Mother's present height?
4. Female: Age of first monthly period: Years Months
Female: Is the patient pregnant now? YES NO
If YES, due date:

AUTHORIZATION

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to the patient's health. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the patient's medical status.

SIGNATURE OF PATIENT (PARENT/LEGAL GUARDIAN IF A MINOR) DATE


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