Under 18 Medical Dental History

Medical Dental History for Patients Under 18
PATIENT
Today's Date*

MonthDayYear
Patient's Name*

First nameMiddle initialPatient's last name
Prefers to be called
Sex:*

MaleFemale
Birth date*

MonthDayYear
Sports, activities
Social Security #
School
Grade
Home Address*

Street Address Line 2

City, State, Zip codeState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
PARENT/GUARDIAN
Patient lives with (check all that apply)*

MotherFatherStepmotherStepfatherGrandparent(s)
Father's full name
Father's home address (if different from patient)
City, State, Zip Code
Father's Cell Phone

Area CodePhone Number
Father's Email
example@example.com
Father's occupation
Mother's full name
Mother's home address (if different from patient)
City, State, Zip Code
Mother's cell phone

Area CodePhone Number
Mother's Email address
example@example.com
Occupation
DENTIST
Patient's General Dentist*
City, State*
Last Seen*

MonthDayYear
Date
Reason*
Other Dentist Being Seen
City, State
Reason
GENERAL INFORMATION
What concerns you about your child's teeth?*
What concerns your child about his/her teeth?*
How does your child feel about orthodontic treatment?*
Who suggested your child might need orthodontic treatment?*
Why did you select our office?*
Describe any previous orthodontic consultations.
Does your child play a musical instrument?
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?*
Home Address (if different from patient)
CIty, State, Zip Code
Cell phone (if different than one listed earlier)

Area CodePhone Number
Email address (if different than one listed earlier)
example@example.com
Social Security #*
Who will generally bring the patient to appointments?*
DENTAL INSURANCE
Primary policy holder's full name
Birth date

MonthDayYear
Relationship to patient
Social Security #
Home Address (if different than patient)
City, State, Zip Code
Insurance Company
Member/Subscriber ID#
Group #
Secondary policy holder's full name
Birth Date

MonthDayYear
Relationship to patient
Social Security #
Home address (if not same as patient)
City, State, Zip Code
Insurance company
Member/Subscriber ID#
Group #
PHYSICIAN
Patient's Pediatrician/Physician*
City, State*
Most recent physical exam:*

MonthDayYear
Patient's other physician being seen:
City, State
Reason
Your answers to the following questions are for our office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions choose yes, no, or dk/u (don't know/understand).
MEDICAL HISTORY

Now or in the past has your child had:
Birth defects or hereditary problems?*

yesnodk/u
Bone fractures or major injuries?*

yesnodk/u
Any injuries to face, head, neck?*

yesnodk/u
Arthritis or joint problems?*

yesnodk/u
Cancer, tumor, radiation treatment or chemotherapy?*

yesnodk/u
Endocrine or thyroid problems?*

yesnodk/u
Diabetes or low sugar?*

yesnodk/u
Kidney problems?*

yesnodk/u
Immune system problems?*

yesnodk/u
History of osteoporosis?*

yesnodk/u
Gonorrhea, syphilis, herpes, sexually transmitted diseases?*

yesnodk/u
AIDS or HIV positive?*

yesnodk/u
Hepatitis, jaundice, or other liver problems?*

yesnodk/u
Polio, mononucleosis, tuberculosis, pneumonia?*

yesnodk/u
Seizures, fainting spells, neurologic problems?*

yesnodk/u
Mental health disturbance or depression?*

yesnodk/u
History of eating disorder (anorexia/bulimia)?*

yesnodk/u
Frequent headaches or migraines?*

yesnodk/u
High or low blood pressure?*

yesnodk/u
Excessive bleeding or bruising tendency, anemia?*

yesnodk/u
Chest pain, shortness of breath, tire easily, swollen ankles?*

yesnodk/u
Heart defects, heart murmur, rheumatic heart disease?*

yesnodk/u
Angina, arteriosclerosis, stroke or heart attack?*

yesnodk/u
Skin disorder (other than common acne)?*

yesnodk/u
Does your child eat a well-balanced diet?*

yesnodk/u
Vision, hearing or speech problems?*

yesnodk/u
Frequent ear infections, colds, throat infections?*

yesnodk/u
Asthma, sinus problems, hay fever?*

yesnodk/u
Tonsil or adenoid condition?*

yesnodk/u
Does your child frequently breathe through his/her mouth?*

yesnodk/u
Has your child ever taken intravenous bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders or cancer?*

yesnodk/u
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel(ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?*

yesnodk/u
Has your child had allergies or reactions to any of the following:
Local anesthetics (novocaine, lidocaine, xylocaine)*

yesnodk/u
Latex (gloves, balloons)*

yesnodk/u
Aspirin*

yesnodk/u
Ibuprofen (Motrin, Advil)*

yesnodk/u
Penicillin*

yesnodk/u
Other antibiotics*

yesnodk/u
Metals (jewelry, clothing snaps)*

yesnodk/u
Acrylics*

yesnodk/u
Plant pollens*

yesnodk/u
Animals*

yesnodk/u
Foods*

yesnodk/u
Other substances*

yesnodk/u
DENTAL HISTORY

Now or in the past has your child had:
Erupting teeth very early or very late?*

yesnodk/u
Primary (baby) teeth removed that were not loose?*

yesnodk/u
Permanent or extra (supernumerary) teeth removed?*

yesnodk/u
Supernumerary (extra) or congenitally missing teeth?*

yesnodk/u
Chipped or injured primary or permanent teeth?*

yesnodk/u
Any sensitive or sore teeth?*

yesnodk/u
Any lost or broken fillings?*

yesnodk/u
Jaw fractures, cysts, infections?*

yesnodk/u
Any teeth treated with root canals or pulpectomies?*

yesnodk/u
Frequent canker sores or cold sores?*

yesnodk/u
History of speech problems or speech therapy?*

yesnodk/u
Difficulty breathing through nose?*

yesnodk/u
Mouth breathing habit or snoring at night?*

yesnodk/u
History of speech problems?*

yesnodk/u
Frequent oral habits (sucking finger, chewing pen, etc.)?*

yesnodk/u
Teeth causing irritation to lip, cheek or gums?*

yesnodk/u
Tooth grinding or clenching?*

yesnodk/u
Clicking, locking in jaw joints?*

yesnodk/u
Soreness in jaw muscles or face muscles?*

yesnodk/u
Has your child been treated for TMJ or TMD problems?*

yesnodk/u
Any broken or missing fillings?*

yesnodk/u
Any serious trouble associated with previous dental treatment?*

yesnodk/u
Has your child ever been diagnosed with gum disease or pyorrhea?*

yesnodk/u
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 flouride supplements that your child takes.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Does your child take antibiotic pre-medication before any dental procedures?
Does your child have (or ever had) a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child's face or jaws?
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?*
How often does your child floss?*
RELEASE AND WAIVER
By signing below:

I authorize release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company.

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.
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear
Should be Empty:

Medical Dental History for Patients Under 18

PATIENT

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

PHYSICIAN

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER