Sutton - Medical/Dental History Form (Ortho)

Medical/Dental History Form (Ortho)
Date*

MonthDayYear
Date
Patient's last name*
First name*
Middle initial*
Prefers to be called*
Hobbies, activities*
Birth date*
Sex*

MaleFemale
Social Security #*
School*
Email*
example@example.com
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Parent/Guardian
Custodial parent(s) name(s)*
Patient lives with (check all that apply)*

MotherFatherStepmotherGrandparent(s)Other
Father's full name*
Title:*

MrDrOther
SSN*
DOB*
Email*
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone (if different)

Area CodePhone Number
Cell phone

Area CodePhone Number
Work phone

Area CodePhone Number
Mother's full name*
Title:*

MrsMsDrOther
SSN*
Email*
example@example.com
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (if different)

Area CodePhone Number
Cell phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Dental Insurance
Primary policy holder's full name*
Birth date*
Social Security #*
Relationship to patient*
Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company*
Group #*
ID#*
Does this policy have orthodontic benefits?*

YesNoDon't Know
Dental Insurance
Policy Holder's Full Name*
Insurance Company*
Physician
Patient's Physician*
City, State*
Last seen

MonthDayYear
Date
Reason*
Next appointment*

MonthDayYear
Date
Most recent physical exam*
Other physician/health care providers being seen now:
Name
City, State
Reason
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.

For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Medical History

Now or in the past, has your child had:
Birth defects or hereditary problems?*
Bone fractures or major injuries?*
Any injuries to face, head, neck?*
Arthritis or joint problems?*
Cancer, tumor, radiation treatment or chemotherapy?*
Endocrine or thyroid problems?*
Diabetes or low sugar?*
Kidney problems?*
Immune system problems?*
History of osteoporosis?*
Gonorrhea, syphilis, herpes, sexually transmitted diseases?*
AIDS or HIV positive?*
Hepatitis, jaundice, or other liver problems?*
Polio, mononucleosis, tuberculosis, pneumonia?*
Seizures, fainting spells, neurologic problems?*
Mental health disturbance or depression?*
History of eating disorder (anorexia, bulimia)?*
Frequent headaches or migraines?*
High or low blood pressure?*
Excessive bleeding or bruising, anemia?*
Chest pain, shortness of breath, tire easily, swollen ankles?*
Heart defects, heart murmur, rheumatic heart disease?*
Angina, arteriosclerosis, stroke or heart attack?*
Skin disorder (other than common acne)?*
Does your child eat a well-balanced diet?*
Vision, hearing, or speech problems?*
Frequent ear infections, colds, throat infections?*
Asthma, sinus problems, hayfever?*
Tonsil or adenoid condition?*
Does your child frequently breathe through his/her mouth?*
Has your child ever taken intravenous bisphosphonatessuch as Zometa (zolendromic acid), Aredia (pamidronate)or Didronel (etidronate) for bone disorders or cancer?*
Has your child ever taken oral bisphosphonates such asFosamax (alendronate), Actonel(ridendronate), Boniva(ibandronate), Skelid (tiludronate) or Didronel (etidronate)for bone disorders?*
Has your child had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)*
Latex (gloves, balloons)*
Aspirin*
Ibuprofen (Motrin, Advil)*
Penicillin*
Other antibiotics*
Metals (jewelry, clothing snaps)*
Acrylics*
Plant pollens*
Animals*
Foods*
Other substances*
Dental History

Now or in the past, has your child had:
Erupting teeth very early or very late?*
Primary (baby) teeth removed that were not loose?*
Permanent or extra (supernumerary) teeth removed?*
Supernumerary (extra) or congenitally missing teeth?*
Chipped or injured primary or permanent teeth?*
Any sensitive or sore teeth?*
Any lost or broken fillings?*
Jaw fractures, cysts, infections?*
Any teeth treated with root canals or pulpotomies?*
Frequent canker sores or cold sores?*
History of speech problems or speech therapy?*
History of speech problems or speech therapy?*
Difficulty breathing through nose?*
Mouth breathing habit or snoring at night?*
History of speech problems?*
Frequent oral habits (sucking finger, chewing pen, etc)?*
Teeth causing irritation to lip, cheek or gums?*
Tooth grinding or clenching?*
Clicking, locking in jaw joints?*
Soreness in jaw muscles or face muscles?*
Has your child been treated for “TMJ” or “TMD” problems?*
Any broken or missing fillings?*
Any serious trouble associated with previous dental treatment?*
Has you child ever been diagnosed with gum disease or pyorrhea?*
Patient Health Information
Do you think that any of your child’s activities affect his/her face, teeth or jaws? How?*
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Does your child take antibiotic premedication before any dental procedures?*

YesNo
Does your child have (or ever had) a substance abuse problem?*

YesNo
Does your child chew or smoke tobacco?*

YesNo
Have you noticed any unusual changes in your child’s face or jaws?*

YesNo
Any other physical problems?
Family Medical History

Have the parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
How often does your child brush?
Floss?
Release And Waiver
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.*

Clear
Date*

MonthDayYear
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.*

Clear
Date*

MonthDayYear
Date
In an effort to improve communications with our patients, Sutton Children's Dentistry & Orthodontics will be emailing and/or texting appointment reminders. If youare interested in being part of this service, please enter your information below. Please be aware that this email address may also be used to email you personal information (i.e.. Receipts, Invoices, Letters) relating to your dental care. Your information is only used for communications with you and other dental professionals. We do NOT share or sell personal information.
Personal Email:*
example@example.com
Mobile Phone #*

Area CodePhone Number
I hereby authorize the dentists and staff at Sutton Children's Dentistry & Orthodontics to perform diagnostic aids including an examination, x-rays, photographs, models, cleaning and fluoride treatment, when necessary, as the standard of care to properly diagnose and record any and all dental conditions. I authorize my insurance company to pay Sutton Children's Dentistry & Orthodontics all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance, all broken appointment fees and all late payment services charges. I also understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of Sutton Children's Dentistry & Orthodontics. This consent is to remain in effect from the date indicated until canceled in writing.
Authorized Signature*

Clear
Relationship to Child:*
Should be Empty:

Medical/Dental History Form (Ortho)

Parent/Guardian

Dental Insurance

Dental Insurance

Physician

Dental History

Patient Health Information

Family Medical History

Release And Waiver