Medical History Form - Child

About Your Child

First name

Last name

Preferred Name:

Gender

Home Address

Email

Phone

Birthday

Month

Day

Year

Age

School & Grade

Patient resides with:

Both Parents

Mother

Father

Other

How do you prefer we contact you to confirm appointments?

Text

Email

Source of referral:

Describe the orthodontic problem in your own words:

Parents & Account Information

Parent 1 Information

Parent 1 Full Name

Parent 1 Email

Parent 1 Phone

Parent 2 Information

Parent 2 Full Name

Parent 2 Email

Parent 2 Phone

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your child's dental care. All information will be kept completely confidential.

Medical History

Physician's Name:

Has your child experienced any health problems? If yes, please explain:

Any major change in your child’s health recently? If yes, please explain:

Is your child currently under physician’s care? If yes, please explain:

Is your child currently taking medications? If yes, please list:

Is your child allergic to any medications? If yes, please list:

Has your child’s tonsils or adenoids been removed? If yes, please list date.

Does your child smoke?

Yes

No

Growth Information for Patients Under 16 Years of Age

Your answers to the following questions are needed because growth can be an important factor in orthodontic treatment planning.

Has your child reached puberty?

Yes

No

IF your child has started menstruation, please indicate date started:

IF your son's voice has changed, please indicate the date when this changed:

Do you feel growth is completed?

Yes

No

Dental History

Dentist's Name and date of last dental visit:

Frequency of dental checkups:

Twice a year

Once a year

Only if a problem exist

Never

Does your child have a sensitive / active gag reflex?

Yes

No

Is your child frightened about dental treatment? If yes, please explain.

Has your child had any face or dental injuries? If yes, please explain.

Does your child play sports? If yes, please list sports most commonly played, as well as whether they wear a mouth guard while playing sports.

Have teeth (either primary or permanent) been removed?

Yes

No

Has your child had any previous orthodontic treatment?

Yes

No

Is there a history of thumb or finger sucking? If yes, when did it stop?

Does your child have any speech challenges? If so, which sounds?

Does your child breathe through their mouth? If so, please indicate whether it is while awake, asleep or both.

Is your child allergic to any of the following?

Dental Anesthetics

Any Metal/Plastic

Latex

I the undersigned have given the above dental and medical information, have reviewed it and find it accurate. If there are any changes to this record, I will inform this practice.

Please write your signature here.

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