Child Health History Form

Fields marked with an * are required


Minor Patient Information













Marital Status:

SingleMarriedDivorced


father's Information














Mother's Information














Insurance Information






Is policy connected with your union?

YesNo


Does the patient have DUAL COVERAGE? If yes, please complete the following secondary insurance info:

YesNo






Is this dual insurance policy connected with your union?

YesNo



General Information








Currently under dental treatment?

YesNo





Currently under physician treatment?

YesNo


Any History of:

Thumb or finger sucking?

YesNo


Grinding of teeth?

YesNo


Frequent headaches or jaw pain?

YesNo

Difficulty eating any foods?

YesNo

Speech difficulty or speech therapy?

YesNo




Medical History

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 in general good health at this time?

YesNo

Is the patient under any medical treatment now?

YesNo

Is the patient taking any drugs or medications?

YesNo

Has the patient ever had any adverse response to any drugs, including penicillin?

YesNo

Is the patient allergic to any known materials resulting in hives, asthma, eczema, etc.?

YesNo

Is the patient allergic to latex?

YesNo

Has the patient ever had any major operations including hip/joint replacement?

YesNo


Does the patient have any wounds healed slowly or presented other complications?

YesNo

Has the patient ever had any radiation therapy or chemotherapy?

YesNo

Has the patient ever had a serious accident involving head injuries?

YesNo

Has the patient had a history of any of the following?

AsthmaHeart murmurTumor or growthTonsillitisAids or HIV positiveFaintingDiabetesMigraine headachesCardiovascular diseaseHerpesRespiratory problemsBone disorderExcessive bleedingEpilepsyArthritis or painful jointsDrug abuseCancerSinus problemsBlood diseaseEmotional problemsConvulsionsInfectious diseaseAlcoholismSexually transmitted diseaseHay feverRheumatic feverDizzinessImmune system problemsHepatitis or liver diseaseHearing disorderOther


Does the patient snore?

YesNo

Does the patient have unexplained awakenings from sleep?

YesNo

Does the patient stop breathing for short periods during sleep?

YesNo

Does the patient get excessively tired during the day and/or fall asleep when you should be awake?

YesNo

Is the patient on a diet at this time?

YesNo

Does the patient have a history of fainting?

YesNo

Is the patient pregnant?

YesNo

Has the patient ever smoked or used Tobacco products?

YesNo

FEMALES: Started Menstruation?

YesNo



Dental History

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.



Do the patient's gums bleed?

YesNo

Has the patient ever had gum disease, or periodontal treatment?

YesNo

Does the patient frequently get sore spots in the mouth?

YesNo

Does the patient have any dental complaints at the present time?

YesNo

Does the patient experience frequent headaches?

YesNo

Does the patient have a history of back or neck injuries? Whiplash?

YesNo

Does the patient have any clicking or popping of your jaw? (TMJ)

YesNo

Does the patient have pain in or around your ears?

YesNo

Does any part of the patient's mouth hurt when clenched?

YesNo

Does the patient habitually clench or grind their teeth during the night or day?

YesNo

Does the patient chew on only one side of their mouth?

YesNo


Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc)?

YesNo


Has the patient ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?

YesNo

Has the patient ever taken medication for treatment of Osteoporosis?

YesNo


Patient Emergency Info

In case of emergency, contact:




Purpose of consent (HIPAA)

By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations. Where appropriate, a credit report may be obtained.