Child Health History Form
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the FDA.
Tell Us About Your Child
Today's Date
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Middle Name
Last Name
Nickname
Child's Birth Date
*
-
Month
-
Day
Year
Date
Child's Age
*
Child's Gender
*
Female
Male
Child's Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
-
Area Code
Phone Number
Child's Cell Phone Provider
Child's School
Child's Hobbies/Sports
Child's Grade
Who is accompanying the child today? (Please include name and relation)
Do you have legal custody of this child?
*
Yes
No
Please list other siblings and their ages:
Referral Source
*
Other family members seen by us:
Name of child's dentist:
Date of Last Visit
-
Month
-
Day
Year
Date
Parent and/or Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Patient
*
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Full Name
First Name
Last Name
Relationship to Patient
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Responsible Party Information
Person Responsible for Account:
*
Marital Status
*
Single
In a Relationship
Married
Widowed
Divorced
Separated
Relationship to Child
*
Mother
Stepmother
Guardian
Father
Stepfather
Other
Full Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Employer
Occupation
Cell Number
*
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Emergency Contact
Full Name
*
First Name
Middle Name
Last Name
Cell Number
*
-
Area Code
Phone Number
Relationship to Patient
*
Mother
Stepmother
Guardian
Father
Stepfather
Other
Child's Orthodontic Insurance
If you have orthodontic insurance coverage for the child, please fill out below:
Do you have orthodontic coverage?
*
Yes
No
Unsure
Do you have dental coverage?
*
Yes
No
Unsure
Insurance Company Name
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone
-
Area Code
Phone Number
Group Number (Plan, Local or Policy #)
Insured's Name
First Name
Last Name
Relation
Insured's Birthdate
-
Month
-
Day
Year
Date
Insured's ID and/or SSN #:
Insured's Employer
Employer's Phone Number
-
Area Code
Phone Number
Medical History
Does the child have a personal physician?
*
Yes
No
Child's Physician's Name
Date of Last Visit
-
Month
-
Day
Year
Date
Child's current physical health is:
*
Good
Fair
Poor
Have adenoids or tonsils been removed?
*
Yes
No
Has puberty begun?
*
Yes
No
GIRLS: Has menstruation begun?
Yes
No
Does the child brush teeth daily?
*
Yes
No
Does the child floss daily?
*
Yes
No
Is the child taking prescription/over-the-counter drugs?
*
Yes
No
Please list each prescription/over the counter medication the child is taking and why it was prescribed:
Has the child ever had any of the following diseases or medical problems? (Please check all that apply)
Abdominal Bleeding/Hemophilia
AIDS
Anemia
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Prosthetics
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Are the child's immunizations current?
*
Yes
No
Would you like to discuss anything with the doctor in private?
*
Yes
No
Please list any serious medical condition(s) that the child has had:
Does/did the child have any of the following habits? (Please check all that apply)
*
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Speech Problems
Thumb/Finger Sucking
Tongue Thrust
Pacifier Usage
None
Please list any musical instruments the child has played:
Is the child allergic to any of the following (please check all that apply):
Dental Anesthetics
Jewelry/Metals
Latex
Antibiotics (please specify below)
Foods (please specify below)
Other
List any other known allergies:
What are the main concerns that you would like orthodontics to accomplish?
*
Has the child ever had or been evaluated for orthodontic treatment?
*
Yes
No
Has the child ever experienced pain/discomfort in the jaw joint (TMJ/TMD)?
*
Yes
No
The child's current dental health is:
*
Good
Fair
Poor
Has the child ever had an injury to their: (please select all that apply)
Mouth
Teeth
Chin
Does the child have speech problems?
*
Yes
No
Does the child breathe through their mouth?
While Awake
While Asleep
Does the child like their smile?
*
Yes
No
If not, what would they like to change about their smile?
Orthodontic Information Release Per HIPAA
Under the law, we must have your signature on a dated consent form and/or an authorization form of the acknowledgement of this notice, before we will use or disclose your PHI for certain purposes.
Patient Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
When necessary, do you authorize the release of information including diagnosis, records, claims, and financial information to a third party?
Yes
No
Who can this information be released to?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. Prompt notification of any medical and/or insurance changes during active treatment is highly recommended. Failure to communicate changes in insurance may affect your coverage resulting in a decreased insurance benefit. I understand that I am responsible for payment of services rendered and for paying any co-payment that my insurance does not cover, including the deductible. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature of Parent or Guardian
*
Clear
Signature of Periago Staff
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: