Child New Patient Information

Patient Information

* Patient Name: (Required)

Male Female

Social Security Number: Birth Date: Age:
Home Address: City: State: Zip:

Primary Phone Number: home cell

Name of Mobile Phone Carrier

E-mail:
School: Grade:
List any sports or extracurricular activities:
Siblings (names and ages):

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Parent / Guardian Information

Parents' Marital Status

Single Married Divorced Widowed Significant Other

Mother Step-Mother Guardian Other

Name: Social Security Number: Birth Date: Driver License Number:
Address (if different than child's): City: State: Zip:

Phone Number: home cell

Name of Mobile Phone Carrier

Secondary Phone Number: home cell

Name of Mobile Phone Carrier

Employer's Name: Occupation:

Father StepFather Guardian Other

Name: Social Security Number: Birth Date: Driver License Number: Address (if different than child's): City: State: Zip:

Phone Number: home cell

Name of Mobile Phone Carrier

Secondary Phone Number: home cell

Name of Mobile Phone Carrier

Employer's Name: Occupation:

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Emergency Contact Information

Emergency Contact Name (other than parent): Phone Number: Relation to child: Address: City: State: Zip: {C}

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Insurance Information

Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth:
Employer: Work Phone Number: Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth:
Employer: Work Phone Number: {C}

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Dental History

General Dentist: Last Visit:

How did you hear about our Practice?

Ad Internet Family/Friend Physician Other
Name of person referring (if applicable) :

What are the main concerns you would like orthodontics to accomplish?

Concerns:

Is a family member currently in treatment?

Yes No

Has a family member received treatment in our office?

Yes No

Has your child visited an orthodontist before?

Yes No
When: Reason:

Have we treated any other family members?

Yes No
Name:

Have your child's tonsils or adenoids been removed?

Yes No

Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Does your child have any missing or extra permanent teeth?

Yes No

Has your child ever had an injury to (select all that apply):

Teeth Mouth Chin

Does your child have speech problems?

Yes No
If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply)?

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

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Medical History

Is your child currently being treated by a physician?

Yes No
Reason: Physician: Last Visit: Phone:

Does your child have any allergies/sensitivities to medications or latex?

Yes No
If yes, please list:

Is your child currently taking any prescription or over-the-counter medications?

Yes No
Please list, with dosage:

Has puberty and/or menstruation begun?

Yes No NA

Has your child had any serious illnesses or operations? If yes, describe:

Has your child ever had a blood transfusion?

Yes NoIf yes, give approximate dates:

Is your child pregnant? Yes NoNursing? Yes NoTaking birth control pills? Yes No

Check if your child has or has ever had any of the following:

Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems

Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia

Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever

Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)

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