Today's Date: August 28, 2008

1.  Tell Us About Your Child:
Nickname:
Child’s Name:
E-mail Address:
SS#: Birthdate:
Age: Grade: Male Female
School:
Hobbies/Sports:
Child’s Home Phone #:
Child’s Home Address:

2.  Who Is Accompanying Your Child Today?
Name: Relation:
Do you have legal custody of this child? Yes No
Whom may we thank for referring you?
List brothers/sisters with ages:

General Dentist:
Last Visit Date:
 
Parent’s Marital Status:
Single Partnered Divorced
Married Separated Widowed

3.  Mother’s Information:
Step Mother Guardian
Name: Birthdate:
Work #: Ext: Home #:
Employer:
How Long at Current Job?
Job Title:
SS#: DL#:

Father’s Information:
Step Father Guardian
Name: Birthdate:
Work #: Ext: Home #:
Employer:
How Long at Current Job?
Job Title:
SS#: DL#:

4.  Person Responsible for Account:
Name: Relation:
Billing Address:

Previous Address:

Home #: DL#:
Employer:
Work #: Ext: SS#:

Who is responsible for making appointments?
Name:
Work #: Ext: Home #:

5.  Primary Orthodontic Insurance:
Orthodontic Coverage? Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy#):
Policy Owner’s Name:
Relationship to Patient:
Policy Owner’s Birthdate: SS#:
Policy Owner’s Employer:
Employer’s Address:

Secondary Orthodontic Insurance:
Orthodontic Coverage? Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy#):
Policy Owner’s Name:
Relationship to Patient:
Policy Owner’s Birthdate: SS#:
Policy Owner’s Employer:
Employer’s Address:

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

Has your child ever taken Phen-Fen?
Yes No (Also known as Redux or Pondimin)
If yes, when?
Has your child ever been evaluated or had orthodontic treatment before?
Yes No
Have there been any injuries to the face, mouth, teeth or chin?
Yes No
List any musical instruments played:
Have adenoids or tonsils been removed?
Yes No
Has your child been informed of any missing or extra permanent teeth?
Yes No
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Yes No
Does your child brush his/her teeth daily?
Yes No
Floss his/her teeth daily?
Yes No
Child’s physician:
Phone #: Date of Last Visit:
Is your child currently under the care of a physician?
Yes No
Has puberty begun?
Yes No
Has menstruation begun? (Girls)
Yes No
Please describe your child’s current physical health:
Good Fair Poor
Please list all drugs that your child is currently taking:

Please list all drugs/things that your child is allergic to:

7.  Has your child ever had any of the following medical problems?
Y N   Abnormal Bleeding
Y N   ADD/ADHD
Y N   Allergies to any Drugs
Y N   Allergies to Latex/Metals
Y N   Allergies to Plastic
Y N   Any Hospital Stays
Y N   Any Operations
Y N   Artificial Bones/Joints/Valves
Y N   Asthma
Y N   Cancer
Y N   Congenital Heart Defect
Y N   Convulsion/Epilepsy
Y N   Diabetes
Y N   Handicaps/Disabilities
Y N   Hearing Impairment
Y N   Heart Murmur
Y N   Hemophilia
Y N   Hepatitis
Y N   HIV+/AIDS
Y N   Kidney/Liver Problems
Y N   Rheumatic/Scarlet Fever
Y N   Tuberculosis (TB)

Please discuss any medical problems that your child has had:

8.  Has your child ever had any of the following medical problems?
Y N   Clenching/Grinding Teeth
Y N   Lip Sucking/Biting
Y N   Mouth Breather
Y N   Nail Biting
Y N   Nursing Bottle Habits
Y N   Speech Problems
Y N   Thumb/Finger Sucking
Y N   Tongue Thrust

Neighbor or Relative not living with you:
Name:
Phone #:
Address: