Harmony Ortho NP Form (Child)

Physician's name

Approximate date of last physical exam

Date

Has the patient ever been under extended care of a physician?

Yes No

If yes, please explain:

CHECK ANY OF THE FOLLOWING FOR WHICH THE PAITENT HAS BEEN TREATED

Does patient need to be medicated prior to dental appointments?

Yes No

If yes, please explain:

Please answer the following questions:

Not Satisfied

Somewhat Satisfied

Does patient gag easily?

Does patient have frequent ear infections?

Have tonsils and adenoids been removed?

Does patient have special needs? *

Yes No

If yes, please explain:

Are any medications currently being taken? *

Yes No

If yes, please list and explain:

Does patient have any allergies?

Yes No

If yes, please list:

*foods, medications, environmental (i.e hay fever)

General Dentist (name or name of office)

Approximate date of last cleaning

Date

Please answer the following questions: *

Yes

No

Explain Here:

Is there any dental work to be completed? (fillings, crowns, etc.)

Have there been any injuries to the face, mouth, or teeth?

Has patient ever sucked their fingers or thumb?

Does patient have any speech problems?

Has patient ever had orthodontic treatment?

Has any family members had orthodontic treatment?

Is patient a mouth breather?

Have you been informed of extra or missing permanent teeth?

Is there pain in the jaw? (please indicate right, left, or both)

Is there popping or clicking in the jaw joint(s)? (please indicate right, left, or both)

Does patient clench or grind?

Does patient regularly have headaches?

What is the chief concern that brought you to our office? *

Child Patient Information

Responsible Party No. 1

Responsible Party No. 2

Insurance Information

Emergency Contact Information

Patient Medical History

Patient Dental History