Child Medical History Form Patient Last Name First Name MI Preferred Name Hobbies/Activities Date of Birth Social Security # Sex: Male Female Grade School Name Home Address City State (e.g. NJ) Zip Code Email Address Home Phone Cell Phone Instagram @ Parent/Guardian(s) Custodial parent(s) name(s) Father Father's full name Title: Mr. Dr. Other Home Address (if different) City State (e.g. NJ) Zip Code Home Phone Cell Phone Work Phone Email Address Instagram Mother Mother's full name Title: Mrs. Ms. Dr. Other Home Address (if different) City State (e.g. NJ) Zip Code Home Phone Cell Phone Work Phone Email Address Instagram Dentist Patient's Dentist Address City State (e.g. NJ) Zip Code Last seen (mm/dd/yyyy) Reason Next Appointment Other dentists being seen: Name City State (e.g. NJ) Reason Physician Patient's Physician Address City State (e.g. NJ) Zip Code Last seen (mm/dd/yyyy) Reason Next Appointment Most Recent Physical Exam Other physicians being seen: Name City State (e.g. NJ) Reason Name City State (e.g. NJ) 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 you might need orthodontic treatment? Why did you select our office? Describe any previous orthodontic treatment or consultations: Sibling name Age Orthodontic treatment? Yes No Where? Sibling name Age Orthodontic treatment? Yes No Where? Sibling name Age Orthodontic treatment? Yes No Where? Sibling name Age Orthodontic treatment? Yes No Where? Have any other family members been treated in this office? Please name them: Financial Responsibility Who is financially responsible for this account? Address (if different) City State (e.g. NJ) Zip Code Home Phone Cell Phone Work Phone Email Address Social Security # Employer Who will be bringing the patient to orthodontic appointments? Dental Insurance Primary policy holder's full name Date of Birth Social Security # Email Address Home Phone Cell Phone Work Phone Address (if different) City State (e.g. NJ) Zip Code Employer Employer's Address City State (e.g. NJ) Zip Code Insurance company Group # ID # Does this policy have orthodontic benefits? Yes No Unsure Medical History 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 unsure. Now or in the past, has your child had: Yes No Unsure Birth defects or hereditary problems? Please explain: Yes No Unsure Bone fractures, or major injuries? Please explain: Yes No Unsure Any injuries to face, head, neck? Please explain: Yes No Unsure Arthritis or joint problems? Please explain: Yes No Unsure Cancer, tumor, radiation treatment or chemotherapy? Please explain: Yes No Unsure Endocrine or thyroid problems? Please explain: Yes No Unsure Diabetes or low sugar? Please explain: Yes No Unsure Kidney problems? Please explain: Yes No Unsure Immune system problems? Please explain: Yes No Unsure History of osteoporosis? Please explain: Yes No Unsure Gonorrhea, syphilis, herpes, sexually transmitted diseases? Please explain: Yes No Unsure AIDS or HIV positive? Please explain: Yes No Unsure Hepatitis, jaundice or other liver problems? Please explain: Yes No Unsure Polio, mononucleosis, tuberculosis, pneumonia? Please explain: Yes No Unsure Stomach ulcers, hyperacidity, acid reflux? Please explain: Yes No Unsure Seizures, fainting spells, neurologic problem? Please explain: Yes No Unsure Mental health disturbance or depression? Please explain: Yes No Unsure History of eating disorder (anorexia, bulimia)? Please explain: Yes No Unsure Frequent headaches or migraines? Please explain: Yes No Unsure High or low blood pressure? Please explain: Yes No Unsure Excessive bleeding or bruising tendency, anemia? Please explain: Yes No Unsure Chest pain, shortness of breath, tire easily, swollen ankles? Please explain: Yes No Unsure Heart defects, heart murmur, rheumatic heart disease? Please explain: Yes No Unsure Angina, arteriosclerosis, stroke or heart attack? Please explain: Yes No Unsure Skin disorder (other than common acne)? Please explain: Yes No Unsure Do you eat a well-balanced diet? Please explain: Yes No Unsure Vision, hearing, or speech problems? Please explain: Yes No Unsure Frequent ear infections, colds, throat problems? Please explain: Yes No Unsure Asthma, sinus problems, hayfever? Please explain: Yes No Unsure Tonsil or adenoid problems? Please explain: Yes No Unsure Do you frequently breathe through your mouth? Please explain: Has your child had allergies or reactions to any of the following? Yes No Unsure Local anesthetics (novocaine, lidocaine, xylocaine) Please explain: Yes No Unsure Latex (gloves, balloons) Please explain: Yes No Unsure Aspirin Please explain: Yes No Unsure Ibuprofen (Motrin, Advil) Please explain: Yes No Unsure Penicillin Please explain: Yes No Unsure Other antibiotics Please explain: Yes No Unsure Metals (jewelry, clothing snaps) Please explain: Yes No Unsure Acrylics Please explain: Yes No Unsure Plant Pollens Please explain: Yes No Unsure Animals Please explain: Yes No Unsure Foods Please explain: Yes No Unsure Other substances Please explain: Dental History Now or in the past, has your child had: Yes No Unsure Permanent or extra (supernumerary) teeth removed? Please explain: Yes No Unsure Supernumerary (extra) or congenitally missing teeth? Please explain: Yes No Unsure Chipped or injured primary or permanent teeth? Please explain: Yes No Unsure Any sensitive or sore teeth? Please explain: Yes No Unsure Any lost or broken fillings? Please explain: Yes No Unsure Jaw fractures, cysts, infections? Please explain: Yes No Unsure Any teeth treated with root canals or pulpotomies? Please explain: Yes No Unsure “Gum boils,” frequent canker sores or cold sores? Please explain: Yes No Unsure Bleeding gums, bad taste or mouth odor? Please explain: Yes No Unsure Food impaction between teeth? Please explain: Yes No Unsure History of speech problems or speech therapy? Please explain: Yes No Unsure Difficulty breathing through nose? Please explain: Yes No Unsure Mouth breathing habit or snoring at night? Please explain: Yes No Unsure Frequent oral habits (sucking finger, chewing pen, etc.)? Please explain: Yes No Unsure Teeth causing irritation to lip, cheek or gums? Please explain: Yes No Unsure Tooth grinding or clenching? Please explain: Yes No Unsure Clicking, locking in jaw joints? Please explain: Yes No Unsure Soreness in jaw muscles or face muscles? Please explain: Yes No Unsure Ringing in ears, difficulty in chewing or opening jaw? Please explain: Yes No Unsure Any teeth treated with root canals or pulpotomies? Please explain: Yes No Unsure Have you ever been treated for “TMJ” or “TMD” problems? Please explain: Yes No Unsure Any serious trouble associated with previous dental treatment? Please explain: Yes No Unsure Have you ever been diagnosed with gum disease or pyrrhea? Please explain: Yes No Unsure Have you ever had an orthodontic consultation or treatment before? Please explain: Patient Health Information Yes No Do you think that your child's activities affect his/her face, teeth, or jaws? 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 Yes No Does your child take antibiotic premedication before any dental procedures? Yes No Does your child have (or ever had) a substance abuse problem? Yes No Does your child chew or smoke tobacco? Yes No 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? (times/day) How often does your child floss? (times/day) Submit with DocuSign
