Under-18 Medical Dental History

1. Patient Information

Patient's last name —

First name —

Middle initial —

Prefers to be called —

Hobbies, activities —

Birth Date —

Sex —

Social Security# (optional) —

School —

Grade —

Email —

Home address —

Cell phone —

City —

State —

Zip —

Home phone —

Parent/Guardian Information

Custodial parent(s) name(s) —

Patient lives with (check all that apply) —

Other —

Father's full name —

Title —

Other —

Occupation —

Email address —

Address (is equal to patient information?) —

Address —

Home phone —

Cell phone —

Work phone —

Mother's full name —

Title —

Other —

Occupation —

Email address —

Address (is equal to patient information?) —

Address —

Home phone —

Cell phone —

Work phone —

Dentist

Patient's Dentist —

Address —

City —

State —

Last seen —

Reason —

Next appointment —

Other dentist: Name —

City —

State —

Reason —

General Information

What concerns you about your child's teeth? —

What concerns your child about his/her teeth? —

How does your child feel about orthodontic treatment? —

Who suggested that your child might need orthodontic treatment? —

Why did you select our office? —

Describe any previous orthodontic treatment or consultations —

Does your child play a musical instrument? —

Have Siblings? —

Have any other family members been treated in this office? Please name them. —

2. Financial Responsibility

Who is financially responsible for this account? —

Address (is equal to patient information?) —

Address —

City —

State —

Zip —

Home phone —

Cell phone —

Email address(es) —

Social Security # —

Employer —

Who will be responsible for bringing the patient to orthodontic appointments? —

3. Insurance Information

Dental Insurance

Primary policy holder's full name —

Birth date —

Social Security # —

Relationship to patient —

Address (is equal to patient information?) —

Phone (is equal to patient information?) —

Address —

Phone —

Employer —

Address —

Insurance company —

Group # —

ID # —

Does this policy have orthodontic benefits? —

Secondary policy holder's full name —

Birth date —

Social Security # —

Relationship to patient —

Address (is equal to patient information?) —

Phone (is equal to patient information?) —

Address —

Phone —

Employer —

Address —

Insurance company —

Group # —

ID # —

Does this policy have orthodontic benefits? —

Medical Insurance

Policy holder's full name —

Insurance Company —

4. Medical Information

Physician

Patient's Physician —

City —

State —

Last seen —

Reason —

Next appointment —

Most recent physical exam —

Other physicians/health care providers being seen now:

Name —

City —

State —

Reason —

Name —

City —

State —

Reason —

Medical History

Now or in the past, has your child had:

Birth defects or hereditary problems? —

Bone fractures or major injuries? —

Any injuries to face, head, neck? —

Arthritis or joint problems? —

Cancer, tumor, radiation treatment or chemotherapy? —

Endocrine or thyroid problems? —

Diabetes or low sugar? —

Kidney problems? —

Immune system problems? —

History of osteoporosis? —

Gonorrhea, syphilis, herpes, sexually transmitted diseases? —

AIDS or HIV positive? —

Hepatitis, jaundice, or other liver problems? —

Polio, mononucleosis, tuberculosis, pneumonia? —

Seizures, fainting spells, neurologic problems? —

Mental health disturbance or depression? —

History of eating disorder (anorexia, bulimia)? —

Frequent headaches or migraines? —

High or low blood pressure? —

Excessive bleeding or bruising, anemia? —

Chest pain, shortness of breath, tire easily, swollen ankles? —

Heart defects, heart murmur, rheumatic heart disease? —

Angina, arteriosclerosis, stroke or heart attack? —

Skin disorder (other than common acne)? —

Does your child eat a well-balanced diet? —

Vision, hearing, or speech problems? —

Frequent ear infections, colds, throat infections? —

Asthma, sinus problems, hayfever? —

Tonsil or adenoid condition? —

Does your child frequently breathe through his/her mouth? —

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), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders? —

Has your child had allergies or reactions to any of the following?

Local anesthetics (novocaine, lidocaine, xylocaine) —

Ibuprofen (Motrin, Advil) —

Aspirin —

Other antibiotics —

Penicillin —

Acrylics —

Metals (jewelry, clothing snaps) —

Animals —

Plant pollens —

Other substances —

Foods —

Other substances —

Dental History

Now or in the past, has your child had:

Erupting teeth very early or very late? —

Primary (baby) teeth removed that were not loose? —

Permanent or extra (supernumerary) teeth removed? —

Supernumerary (extra) or congenitally missing teeth? —

Chipped or injured primary or permanent teeth? —

Any sensitive or sore teeth? —

Any lost or broken fillings? —

Jaw fractures, cysts, infections? —

Any teeth treated with root canals or pulpotomies? —

Frequent canker sores or cold sores? —

History of speech problems or speech therapy? —

Difficulty breathing through nose? —

Mouth breathing habit or snoring at night? —

History of speech problems? —

Frequent oral habits (sucking finger, chewing pen, etc)? —

Teeth causing irritation to lip, cheek or gums? —

Tooth grinding or clenching? —

Clicking, locking in jaw joints? —

Soreness in jaw muscles or face muscles? —

Has your child been treated for “TM” or “TMD” problems? —

Any broken or missing fillings? —

Any serious trouble associated with previous dental treatment? —

Has your child ever been diagnosed with gum disease or pyorrhea? —

Patient Health Information

Do you think that any of your child's activities affect his/her face, teeth or jaws? How? —

Medication —

Taken for —

Medication —

Taken for —

Medication —

Taken for —

Medication —

Taken for —

Does your child take antibiotic pre-medication before any dental procedures? —

Does your child have (or ever had) a substance abuse problem? —

Does your child chew or smoke tobacco? —

Have you noticed any unusual changes in your child's face or jaws? —

Any other physical problems? —

Family Medical History

Bleeding disorders —

Diabetes —

Arthritis —

Severe allergies —

Unusual dental problems —

Jaw size imbalance —

Other family medical conditions? —

How often does your child brush? —

Floss —

Pediatric Sleep Questionnaire

1. While sleeping, does your child:

Snore more than half the time? —

Always snore? —

Snore loudly? —

Have “heavy” or loud breathing? —

Have trouble breathing, or struggle to breathe? —

2. Have you ever seen your child stop breathing during the night? —

3. Does your child:

Tend to breathe through the mouth during the day? —

Have a dry mouth on waking up in the morning? —

Occasionally wet the bed? —

4. Does your child:

Wake up feeling unrefreshed in the morning? —

Have a problem with sleepiness during the day? —

5. Has a teacher or other supervisor commented that your child appears sleepy during the day? —

6. Is it hard to wake your child up in the morning? —

7. Does your child wake up with headaches in the morning? —

8. Did your child stop growing at a normal rate at any time since birth? —

9. Is your child overweight? —

10. This child often:

Does not seem to listen when spoken to directly —

Has difficulty organizing tasks and activities —

Is easily distracted by extraneous stimuli —

Fidgets with hands or feet or squirms in seat —

Is “on the go” or often acts if “driven by a motor” —

Interrupts or intrudes on others (e.g., butts into conversations or games) —

5. Release and Waiver

Signature —

6. Medical History Updates or Changes

Change 1

Changes —

Parent/Guardian Signature —

7. Acknowledgement of Receipt of Notice of Privacy Practices

I, (write name and surname), have received a copy of this office's Notice of Privacy Practices. —

Signature —

I refuse to sign this acknowledgement No

Step 8 — Summary

1. Patient Information

Parent/Guardian Information

Dentist

General Information

2. Financial Responsibility

3. Insurance Information

Dental Insurance

Medical Insurance

4. Medical Information

Physician

Other physicians/health care providers being seen now:

Medical History

Now or in the past, has your child had:

Has your child had allergies or reactions to any of the following?

Dental History

Now or in the past, has your child had:

Patient Health Information

Family Medical History

Pediatric Sleep Questionnaire

1. While sleeping, does your child:

3. Does your child:

4. Does your child:

10. This child often:

5. Release and Waiver

6. Medical History Updates or Changes

Change 1

7. Acknowledgement of Receipt of Notice of Privacy Practices