schmidlorthodontics - Child Medical Dental History Form

CONFIDENTIAL

Medical Dental History Form for Patients Under Age 18
PATIENT
Date

MonthDayYear
Patient's name

Last NameFirst NameMiddle Initial
Prefers to be called
Hobbies, activities
Birth date

MonthDayYear
Sex

MaleFemale
Social Security #
School
Grade
Home address

Apt #

CityState

Zip Code
Phone Number
Phone Number Type
E-mail address
Home phone

Area CodePhone Number
PARENT/GUARDIAN
Custodial parent(s) name (s)
Patient lives with (check all that apply)

MotherFatherStepmotherStepfatherGrandparent(s)Other
Mother Information
Mother's full name
Title

Mr.Dr.Other
Occupation
Email address
Address (if different)

Apt #

CityState

Zip Code
Cell Phone (if different):
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
Father Information
Father's full name
Title

Mrs.Ms.Dr.Other
Occupation
Email address
Address (if different)

Apt #

CityState

Zip Code
Cell Phone (if different)
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
DENTIST
Patient’s Dentist
Address

CityState

Zip Code
Last seen

MonthDayYear
Reason
Next appointment
Other dentists/dental specialists now being seen
Name
Address

CityState

Zip Code
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 that your child might need orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultations.
Does your child play a musical instrument?
List Brother / Sister

	Name	Relationship	Age	Had orthodontic treatment?	If yes, where?
1
2
3
4
5
6

Have any other family members been treated in this office?

YesNo
Please name them

FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address (if different from above)

Apt #

CityState

Zip Code
Cell phone
Home phone

Area CodePhone Number
E-mail address(es)
Social Security #
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
DENTAL INSURANCE
Primary policy holder’s full name
Birth date

MonthDayYear
Social Security #
Relationship to patient
Address (if not listed above)

CityState

Zip Code
Phone Number (if not listed above)

Area CodePhone Number
Employer
Address

CityState

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

YesNoDon’t know
Secondary policy holder’s full name
Birth date

MonthDayYear
Social Security #
Relationship to patient
Address (if not listed above)

CityState / Province

Postal / Zip Code
Phone Number (if not listed above)

Area CodePhone Number
Employer
Address

CityState

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

YesNoDon’t know
MEDICAL INSURANCE
Policy holder’s full name
Insurance company
PHYSICIAN
Patient’s Physician
City, State
Last seen

MonthDayYear
Reason
Next appointment

MonthDayYear
Most recent physical exam
Other physicians/health care providers being seen now

	Name	City, State	Reason
1
2
3
4
5
6

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, mark yes, no, or don’t know/understand (dk/u
PATIENT HEALTH INFORMATION
Do you take antibiotic pre-medication before any dental procedures?

YesNo
Does the patient currently have (or ever had) a substance abuse problem?
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
1
2
3
4
5
6

Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child’s face or jaws?
Any other physical problems

	Yes	No	dk/u
Emotional, sensory or developmental issues?
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, neurological problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?

	Yes	No	dk / u
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 adenoids removed?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Has your child ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) ?

	Yes	No	dk/u
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods

	Yes	No	dk / U
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?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?

	Past	Current	Age stopped
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?

CONFIDENTIAL

Medical Dental History Form for Patients Under Age 18

PATIENT

PARENT/GUARDIAN

Mother Information

Father Information

DENTIST

Other dentists/dental specialists now being seen

GENERAL INFORMATION

List Brother / Sister

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

Other physicians/health care providers being seen now

PATIENT HEALTH INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

MEDICAL HISTORY UPDATES

	Yes	No	dk / u
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 your child ever been diagnosed with gum disease or pyorrhea?