Dental History - Child/Teen

Dental History
Child's Full Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Dentist's Name*

First NameLast Name
Dentist's Phone Number*
Dentist's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Last Dental Exam and Cleaning:*

MonthDayYear
Date
How frequent are the Dental Exams?*

Every 3 monthsEvery 6 monthsEvery 12 monthsOther
Any unfinished care to be completed by Dentist? Please specify*
Has your child had Orthodontic treatment before?*

YesNo
At what age did your child have Orthodontic treatment?*
How long did the Orthodontic treatment take?*
Previous Orthodontist's Name*

First NameLast Name
Previous Orthodontist's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Orthodontist's Phone Number*
Any facial or dental injuries? Please specify *
Any history of finger or thumb sucking? Has it stopped?*
Does your child play a musical instrument? Please specify*
Have any teeth been extracted? Please specify*
Please check if you have any of the following:*

Clenching teethGrinding teethJaw joint clickingJaw joint poppingJaw joint sorenessRinging in the earsHeadaches (more than normal)Mouth breathingMuscular soreness around the head and neckSpeech problemsNone of the aboveOther
Guardian's Signature*

Clear
Date*
Should be Empty: