Medical Dental History Form for Patients Under 18

Patient

Date

Patient's last name

First name

Middle initial

Prefers to be called:

Hobbies, activities

Birth date

Gender

Male

Female

Social Security #

School

Grade

Email Adderess(es)

Home address

City

State

Zip

Home phone

Cell phone

Parent/Guardian

Custodial parent(s) name(s)

Patient lives with (check all that apply)

Mother

Father

Step-Mother

Step-Father

Grandparent(s)Other

Other

Fathers full name

Title

Mr

Dr

Other

Other (Title)

Occupation

Email address

Address (if different)

City

State

Zip

Home phone (if different)

Cell phone

Mothers full name

Title

Mrs

Ms

Dr

Other

Other (Title)

Occupation

Email address

Address (if different)

City

State

Zip

Home phone (if different)

Cell phone

Dentist

Patient's dentist

Address

City

State

Zip

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen: Name

Address

City

State

Zip

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?

Brother/sister name

Age

had orthodontic treatment

Yes

No

If yes, where?

Brother/sister name

Age

had orthodontic treatment

Yes

No

If yes, where?

Brother/sister name

Age

had orthodontic treatment

Yes

No

If yes, where?

Brother/sister name

Age

had orthodontic treatment

Yes

No

If yes, where?

Have any other familty members been treated in this office?

Financial Responsibility

Who is financially responsible for this account?

Address (if different from above)

City

State

Zip

Home phone

Cell phone

Email

Social Security #

Employer

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

Dental Insurance

Primary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Inurance company

Group #

ID#

Does this policy have orthodontic benefits?

Yes

No

I don't know

Secondary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Inurance company

Group #

ID#

Does this policy have orthodontic benefits?

Yes

No

I don't know

Medical Insurance

Policy holder's full name

Insurance Company

Physician

Patient's Physician

Address

City

State

Zip

Last seen

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen now

Name

Address

City

State

Zip

Reason

Name

Address

City

State

Zip

Reason

Medical History

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don't know/understand (dk/u).

Now or in the past, have you had:

Birth defects or hereditry problems?

No

Yes

Bone fractures or major injuries?

No

Yes

Any injuries to face, head, neck?

No

Yes

Arthritis or joint problems?

No

Yes

Endocrine or thyroid problems?

No

Yes

Diabetes or low blood sugar?

No

Yes

Kidney problems?

No

Yes

Cancer, tumor, radiation treatment or chemotherapy?

No

Yes

Stomach ulcer, hyperacidity, acid reflux?

No

Yes

Immune system problems?

No

Yes

History of osteoporosis?

No

Yes

Gonorrhea, syphilis, herpes, sexually transmitted diseases?

No

Yes

AIDS or HIV positive?

No

Yes

Hepatitis, jaundice, or any other liver problems?

No

Yes

Polio, mononucleosis, tuberculosis, or pneumonia?

No

Yes

Seizures, fainting spells, neurolgic problems?

No

Yes

Mental health disturbance or depression?

No

Yes

Vision, hearing or speech problems?

No

Yes

History of eating disorder (anorexia, bulimia)?

No

Yes

High or low blood pressure?

No

Yes

Excessive bleeding or bruising, anemia?

No

Yes

Chest pain, shortness of breathe, tire easily, swollen ankles?

No

Yes

Heart defects, heart murmur, rheumatic heart disease?

No

Yes

Angina, arteriosclerosis, stroke or heart attack?

No

Yes

Skin disorder (other than common acne)?

No

Yes

Does your child eat a well-balanced diet?

No

Yes

Frequent headaches or migraines?

No

Yes

Frequent ear infections, cold, throat infections?

No

Yes

Asthma, sinus problems, hayfever?

No

Yes

Tonsil or adenoid condition?

No

Yes

Does your child frequently breathe through your mouth?

No

Yes

Has your child eer taken intravenous biphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?

No

Yes

Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate) for bone disorders?

No

Yes

Have you had allergies or reactions to any of the following?

Local anesthetics (novocaine, lidocaine, xylocaine)

No

Yes

Latex (gloves, balloons)

No

Yes

Asprin

No

Yes

Metals (jewelry, clothing snaps)

No

Yes

Penecillin

No

Yes

Other antibiotics

No

Yes

Ibuprofen (Motrin, Advil)

No

Yes

Acrylics

No

Yes

Plant pollens

No

Yes

Animals

No

Yes

Foods

No

Yes

Other substances

No

Yes

Other

Dental History

Now or in the past, have you had?

Erupting teeth very early or very late?

No

Yes

Primary (baby) teeth removed that were not loose?

No

Yes

Permanent or extra (supernumerary) teeth removed?

No

Yes

Supernumerary (extra) or congenitally missing teeth?

No

Yes

Chipped or injured primary or permanant teeth?

No

Yes

Any sensitive or sore teeth?

No

Yes

Any lost or broken fillings?

No

Yes

Jaw fractures, cysts, infections?

No

Yes

Any teeth treated with root canals or pulpotomies?

No

Yes

Frequent canker sores or cold sores?

No

Yes

History of speech problems or speech therapy?

No

Yes

Difficulty breathing through nose?

No

Yes

Mouth breathing habit or snoring at night?

No

Yes

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

No

Yes

Teeth causing irratation to lip, cheek or gums?

No

Yes

Tooth grinding or clenching?

No

Yes

Clicking, locking in jaw joints?

No

Yes

Soreness in jaw muscles or face muscles?

No

Yes

Has your child been treated for TMU or TMD problems?

No

Yes

Any serious trouble associated with previous dental treatment?

No

Yes

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

No

Yes

Patient Health Information

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

List any medication, nutritional suppliments, herbal medications or non-prescription medicines, including flouride suppliments that your child takes.

Medication

Taken for

Medication

Taken for

Medication

Taken for

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

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

Does your child chew or smoke tobacco?

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

Any other physical problems?

Family Medical History

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disorders

Diabetes

Arthritis

Severe allergies

Unusual dental problems

Jaw size imbalance

Other family medical conditions?

How often does your child brush?

Floss?

Release and Waiver

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Signature

Date

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child's medical or dental health.

Signature

Date

Medical History Updates or Changes

Changes

Signature

Date

Dental Staff Signature

Date

Changes

Signature

Date

Dental Staff Signature

Date

Changes

Signature

Date

Dental Staff Signature

Date