PATIENT INFORMATION
Childs Name
Last
First
Middle
Nickname Gender Male
Female
Address
Street

City
State
Zip
Home Phone Birth date Age S.S.N.

School Grade
Siblings / Children     (Names and ages please)
How did you hear of our office? 

RESPONSIBLE PARTY INFORMATION
Name Marital Status

Last
First
Middle
Residence
Street

City
State
Zip
Mailing Address
Street

City
State
Zip
How long at this address Home Phone Work Phone
Previous Address
(if less than 3 years )
Street

City
State
Zip
Social Security # Birth date Relationship to Patient
Employer Occupation Number Years Employed
Spouse's Name  Relationship to Patient

Last
First
Middle
Employer Occupation Number Years Employed
Social Security # Birth Date Work Phone
INSURANCE INFORMATION
Insured's Name Insured's Social Security #
Insured's Employer
Insurance Company Group Number Local Number
 
Insurance Company Address
Insurance Phone Number
Do you have dual coverage? Yes           No 
Insured's Name Insured's Social security #
Insured's Employer
Insurance Company Group Number Local Number
Insurance Company Address
Insurance Company Phone Number
Insured's Employer
Medical History
Your Childs Physician
Phone Number
Date of Last Visit
 
YES NO     YES NO  
Is your Child taking any medication ? Has your child  had any major operations ?
Is your child allergic to any medications ? Has your child ever been involved in a serious accident ?
Does your child have a history of a major illness ?      

Have you ever had any of the following diseases or medical problems
YES NO     YES NO  
Abnormal Bleeding / Hemophilia Hepatitis / Liver Problems
Anemia Herpes
Arthritis High Blood Pressure
Asthma or Hayfever HIV + / AIDS
Bone Disorders Kidney Problems
Congenital Heart Defect Nervous Disorders
Diabetes Pneumoia
Dizziness Prolonged Bleeding
Epilepsy Radiation / Chemotherapy
Gastrointestinal Disorders Rheumatic Fever
Heart Problems Tuberculosis
Heart Murmur Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
PATIENT DENTAL HISTORY
Childs Dentist
Date of Last Visit
Dentist Phone Number
What Concerns you most about your childs teeth ?
  YES NO
Is your child presently in any dental pain
Has your child ever experienced any unfavorable reaction to dentistry ?
Has your child ever lost or chipped any teeth?
Has your child had any injuries to face, mouth or teeth?
Is any part of your child's mouth sensitive to temperature or pressure ?
Do your child's gums bleed when they brush ?
Does your child have any type of thumb or tongue habit ?
Is your child a mouth breather
Has your child ever seen an orthodontist ?
Has anyone in the family received orthodontic treatment ?
How did they feel about the result ?
What is your child's attitude toward orthodontic treatment ?
Are your child's teeth or jaws ever feel uncomfortable when they awake in the morning?
Is your child aware of their jaw clicking or popping ?
Is your child aware of clenching their teeth during the day ?
Has your child ever been told that they grind their teeth ?
Does your child have "tension" headaches ?
Has your child ever experienced chronic ringing in their ears ?
Are you aware some appointments will be during school hours ?