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Child Health History Form
Gender
Do you have legal custody of this child
Parent's Information
Parent's Marital Status
I request appointment reminders via:
Emergency Contact
Insurance Information (Primary)
Do you have insurance coverage for orthodontic treatment?
Do you have insurance coverage for dentistry?
Insurance Information (Secondary)
Do you have insurance coverage for orthodontic treatment?
Do you have insurance coverage for dentistry?
Health Questionnaire

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

Is the patient taking any medication?
Is the patient allergic to any medication?
Does the patient have a history of major illness?
Has the patient had any major operations?
Have there been any injuries to the face, mouth, teeth, or chin?
Has the patient had a history of any of the following:
Has the patient had any serious illness, operation, or been hospitalized within the past 5 years?
Does the patient have allergies to any of the following?
Dental History
Is the patient presently in any dental pain?
Has the patient ever eperienced any unfavorable reaction to dentistry?
Has the patient ever lost or chipped any teeth?
Is any part of the patient's mouth sensitive to temperature or pressure?
Do the patient's gums bleed when they brush?
Does the patient have any type of thumb or tongue habit?
Has the patient ever seen an orthodontist?
Do the patient's teeth or jaw ever feel uncomfortable when they awake in the morning?
Is the patient aware of their jaw clicking or popping?
Is the patient aware of clenching their teeth during the day?
Has the patient ever been told that they grind their teeth?
Does the patient have tension headaches?
Has the patient ever experienced chronic ringing in their ears?
Does the patient have any speech problems?
How does the patient feel towards orthodontic treatment?
Female Patients Only
Is the patient pregnant?
Has menstruation started (releveant to patient's growth status)?
Acknowledgment of Privacy Policy
I am aware that a copy of this office's Notice of Privacy Policy Practices is available at request. I Agree:
In the subject of minor child, I have listed below the person(s) who may be involved in his/her orthodontic updates and/or transportation.
Authorization
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.