PATIENT INFORMATION

• Sex MaleFemale
• HomeCell
• OK to leave message? YesNo

PARENT/GUARDIAN INFORMATION

• Parent's Marital Status*SingleMarriedDivorcedWidowedSignificant Other
• MotherFatherStep ParentGuardian
• HomeCell
• MotherFatherStep ParentGuardian
• HomeCell

EMERGENCY CONTACT

DENTAL INSURANCE INFORMATION

DENTAL HISTORY

• How did you hear about our practice? AdInternetFamily or FriendPhysicianOther
• What are the main concerns you would like orthodontics to accomplish?
• Has your child visited an orthodontist before? YesNo
• Have we treated any other family members?YesNo
• Has your child ever been prescribed a Fosamax or any other bisphosphonate?YesNo
• Have your child's tonsils or adenoids been removed?YesNo
• Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNo
• Does your child have any missing or extra permanent teeth?YesNo
• Has your child ever had an injury to (select all that apply)?YesNo
• Does your child currently or has your child ever had any of the following habits (select all that apply)? Clenching/Grinding TeethMouth BreathingThumb/Finger SuckingLip Sucking/BitingNail BitingChewing/Eating Problem

MEDICAL HISTORY

• Is your child currently being treated by a physician?YesNo
• Does your child have any allergies/sensitivities to medications or latex?YesNo
• Is your child currently taking any prescription over-the-counter medications?YesNo
• Has puberty and/or menstruation begun?YesNo
• Has your child had any serious illnesses or operations?YesNo
• Has your child ever had a blood transfusion?YesNo
• Is your child pregnant?YesNo
• Check if your child has or has ever had any of the following?
  AnemiaArthritis RheumatismArtificial Heat ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

AUTHORIZATION

• I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.
• I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any Insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by Insurance.
• I understand that where appropriate, credit bureau reports may be obtained.