PATIENT HISTORY FORM (CHILD)

You may complete the Patient History form below and submit the data online. The form is Patient Medical Dental History (CHILD) Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant. Please fill out all items to your best knowledge. Fields marked with an asterisk (*) are required.

    PATIENT INFORMATION

  • MaleFemale
  • HomeCell
  • YesNo

PARENT/GUARDIAN INFORMATION

  • Parent's Marital Status*SingleMarriedDivorcedWidowedSignificant Other
  • MotherFatherStep ParentGuardian
  • HomeCell
  • MotherFatherStep ParentGuardian
  • HomeCell

EMERGENCY CONTACT

DENTAL INSURANCE INFORMATION

DENTAL HISTORY

  • How did you hear about our practice? AdInternetFamily or FriendPhysicianOther
  • Has your child visited an orthodontist before? YesNo
  • Have we treated any other family members?YesNo
  • Has your child ever been prescribed a Fosamax or any other bisphosphonate?YesNo
  • Have your child's tonsils or adenoids been removed?YesNo
  • Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNo
  • Does your child have any missing or extra permanent teeth?YesNo
  • Has your child ever had an injury to (select all that apply)?YesNo
  • Does your child currently or has your child ever had any of the following habits (select all that apply)? Clenching/Grinding TeethMouth BreathingThumb/Finger SuckingLip Sucking/BitingNail BitingChewing/Eating Problem

MEDICAL HISTORY

  • Is your child currently being treated by a physician?YesNo
  • Does your child have any allergies/sensitivities to medications or latex?YesNo
  • Is your child currently taking any prescription over-the-counter medications?YesNo
  • Has puberty and/or menstruation begun?YesNo
  • Has your child had any serious illnesses or operations?YesNo
  • Has your child ever had a blood transfusion?YesNo
  • Is your child pregnant?YesNo
  • Check if your child has or has ever had any of the following?
    AnemiaArthritis RheumatismArtificial Heat ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

    AUTHORIZATION