Child Orthodontic Acquaintance Form

PATIENT INFORMATION

Date

Date of Birth

Age

Sex

Patient Name

School Level

Home Phone

Address

City

State

Zip

Cell Phone

Carrier

Email

I request appointment reminders via:

Email

Text

Both

None

Father's Name

Address (if different)

Occupation/Employer

Cel Phone

City

State

Zip

Mother's Name

Address (if different)

Occupation/Employer

Cel Phone

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 you the best consideration of your orthodontic problem during your 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:

If Yes, due date:

Has the patient had a history of any of the following?

ASTHMA

SEXUALLY TRANSMITTED DISEASE

INFECTIOUS DISEASE

CARDIOVASCULAR DISEASE

TONSILLITIS

HEPATITIS OR LIVER DISEASE

CANCER

BONE DISORDER

DIABETES

HAY FEVER

EMOTIONAL PROBLEMS

ARTHRITIS OR PAINFUL JOINTS

HEART MURMUR

DIZZINESS

ALCOHOLISM

HERPES

AIDS OR HIV POSITIVE

HEARING DISORDER

SINUS PROBLEMS

EXCESSIVE BLEEDING

MIGRAINE HEADACHES

RHEUMATIC FEVER

CONVULSIONS

DRUG ABUSE

TUMOR OR GROWTH

IMMUNE SYSTEM PROBLEMS

OTHER

RESPIRATORY PROBLEMS

FAINTING

BLOOD DISEASE

EPILEPSY

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: Do you:

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:

Snore when sleeping?

Seldom

Sometimes

Often

Breathe through mouth?

Seldom

Sometimes

Often

Have frequent colds?

Seldom

Sometimes

Often

Have frequent stuffy nose?

Seldom

Sometimes

Often

Have frequent sore throat or tonsillitis?

Seldom

Sometimes

Often

Have chewing or swallowing difficulty?

Seldom

Sometimes

Often

Have frequent ear infections?

Seldom

Sometimes

Often

Has the patient recieved medical treatment from an allegist 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

Tongue thrusting

Yes

No

Nail biting

Yes

No

Smoking

Yes

No

Lip biting or sucking

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:

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

Has the patient shown signs of increased growth recently?

Yes

No

Patient's estimated present height?

Father's present height?

Mothers's present height?

Female: Age of first monthly period:

Years

Months

Female: Are you 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 my health. I understand that this information will be held in the strictest confidence and it is my responsiblity to inform this office of any changes in my medical status.

Signature of Patient (Parent/Legal Guardian if a minor)

Date