Child History Form - Scott Family Orthodontics

Patient's Name:

First

Middle

Last

Name Patient Goes By:

Home Address:

Home Phone:

Birthdate:

Age:

Sex:

School & Grade:

Patient's Interests: Sports, Hobbies, Music, Church, School Activities

Brother's Age:

Sister's Age:

Patient's Dentist:

Patient's Physician:

Referred By:

Close Friend or Relative Who is a Patient in this Office:

Person Responsible for Account: (Name)

Name:

Birthdate:

Address: (If Different Than Child's)

HM#:

SS#:

DL#:

Work Phone:

Cell Phone:

Email:

Employer:

Occupation:

Employer Address:

Whom Shall We Contact If Unable to Reach Mother or Father?

(Name, Relationship, Phone)

If You Have Orthodontic Insurance Coverage For The Child, Please Fill Out Below:

Insurance Co. Name:

Insurance Address:

Insurance Phone #:

Insured's ID #:

Group #: (Plan, Local or Policy #)

AUTHORIZATION

THIS OFFICE RESERVES THE RIGHT TO VERIFY THE CREDIT STATUS OF POTENTIAL PATIENTS PRIOR TO EXTENDING CREDIT FOR TREATMENT FEES AND MAY, AT THE DISCRETION OF THIS OFFICE, USE THE SERVICES OF ONE OR MORE CREDIT REPORTING SERVICES. ADDITIONALLY, I HEREBY AUTHORIZE DR. SCOTT TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF INSURANCE BENEFITS, AND I ASSIGN DIRECTLY TO THE DOCTOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I FURTHER AUTHORIZE THE USE OF THIS SIGNATURE ON ALL MY INSURANCE SUBMISSIONS, WHETHER MANUAL OR ELECTRONIC.

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Medical History

Is the patient in good health?

Yes
No

Is the patient under physician's care?

Yes
No

If so, for what reason

Are there any impending operations?

Yes
No

If so, please describe

Is the patient taking prescription medications?

Yes
No

If so, please list

Is the patient allergic to medicines?

Yes
No

If so, please list

Has puberty been reached (start of menstruation or voice change)?

Yes
No

If so and within the last 2 years, when?

Does patient take herbal medicines?

Yes
No

If so, please list

For Females Only:

Is the patient presently pregnant?

Yes
No

Does the patient take birth control pills?

Yes
No

Has patient had or currently have any of the following:

Aids/ Hiv+

Yes
No

Allergies to:

Metals

Yes
No

Vinyl

Yes
No

Latex

Yes
No

Acrylic

Yes
No

Seasonal

Yes
No

Other

Anemia

Yes
No

Arthritis

Yes
No

Asthma

Yes
No

Bone Disorders

Yes
No

Circulatory Problems

Yes
No

Convulsions

Yes
No

Diabetes

Yes
No

Endocrine or Thyroid Problems

Yes
No

Fainting

Yes
No

Frequent Headaches

Yes
No

Glaucoma

Yes
No

Heart Problems

Yes
No

Hepatitis

Yes
No

High Blood Pressure

Yes
No

Kidney Problems

Yes
No

Liver Problems

Yes
No

Neurological Problems

Yes
No

Prolonged Bleeding

Yes
No

Removal of Tonsils & Adenoids

Yes
No

Rheumatic Fever

Yes
No

Sinus Problems

Yes
No

Dental History

HAVE YOU HAD A RECENT DENTAL CHECKUP?

Yes
No

DO YOU BITE LIP/FINGERNAILS?

Yes
No

HAS THERE BEEN A BLOW OR INJURY TO FACE OR TEETH?

Yes
No

HAVE TEETH BEEN KNOCKED OUT OF THE MOUTH AND REIMPLANTED?

Yes
No

IS THERE A FINGER OF THUMB SUCKING HABIT?

Yes
No

ARE THERE SPEECH PROBLEMS?

Yes
No

HAS TREATMENT BEEN RECEIVED FOR THESE PROBLEMS?

Yes
No

ARE THERE SWALLOWING PROBLEMS?

Yes
No

IS THERE CLICKING OR PAIN WHEN OPENING THE JAW?

Yes
No

HAVE YOU EVER HAD JAW JOINT (TMJ) TREATMENT?

Yes
No

IS THERE DIFFICULTY BREATHING THROUGH NOSE (MOUTH BREATHING)?

Yes
No

HAS THE PATIENT EVER HAD SURGERY TO REPAIR CLEFT LIP AND/OR PALATE?

Yes
No

DO THE PATIENT'S YOUR GUMS BLEED WHEN BRUSHING TEETH?

Yes
No

DOES THE PATIENT USE DENTAL FLOSS?

Yes
No

DOES THE PATIENT HAVE FREQUENT SORES IN THE MOUTH OR LIPS?

Yes
No

DOES THE PATIENT PLAY A MUSICAL INSTRUMENT?

Yes
No

IF SO, WHICH ONE

DIETARY HABITS

DOES THE PATIENT EAT BALANCED MEALS (MEAT, VEGETABLES, FRUIT, ETC.)?

Yes
No

DOES THE PATIENT TAKE SUPPLEMENTAL VITAMINS?

Yes
No

IS THERE A HIGH INTAKE OF SWEETS?

Yes
No

DOES THE PATIENT CHEW GUM FREQUENTLY?

Yes
No

DOES THE PATIENT CHEW ICE, EAT LEMONS OR LIMES?

Yes
No

SLEEP HABITS

IS THE PATIENT A SOUND SLEEPER?

Yes
No

DOES THE PATIENT SLEEP WITH YOUR MOUTH OPEN?

Yes
No

DOES THE PATIENT SNORE?

Yes
No

DOES THE PATIENT GRIND TEETH WHILE SLEEPING?

Yes
No

DOES THE PATIENT EVER BEEN TESTED FOR SLEEP APNEA?

Yes
No

RESULTS?

PLEASE DESCRIBE THE PATIENT’S INDIVIDUAL CHARACTER OR NATURE (FOR EXAMPLE: QUIET, OUTGOING, SELF-CONSCIOUS, RESPONSIBLE, LEADER, ONE OF THE GROUP, ETC.)

IF YOU HAVE ANY ADDITIONAL CONCERNS OR QUESTIONS YOU WISH THE DOCTOR TO BE AWARE OF, OR YOU WISH THE DOCTOR TO ANSWER, PLEASE DESCRIBE

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