Online Child Information Form

Patient Information (Child)

Male Female

Birth Date: Age:
Home Address: City: State: Zip:
Primary Phone Number:  Home Home  Cell Cell

School: Grade:
List any sports or extracurricular activities:

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Parent or Guardian Information

Parents' Marital Status

Single   Married Separated/Divorced   Widowed

1st Parent or Guardian

Mother   Father Stepmother Stepfather Grandmother  Grandfather   Guardian

Name:  Birth Date:  Address (if different):  City:  State:  Zip Code: 

Phone Number (if different):  Phone Number Home Cell

E-mail Address: 

Employer's Name:  Occupation: 

2nd Parent or Guardian

Mother   Father Stepmother Stepfather  Grandmother  Grandfather   Guardian

Name:  Birth Date:  Address (if different):  City:  State:  Zip Code: 

Phone Number (if different): Phone Number Phone Number (if different): Home Cell

E-mail Address: 

Employer's Name:  Occupation: 

Dental Insurance Information

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Dental History

General Dentist: Last Visit:

How did you hear about our Practice?

Family/Friend  Dentist Internet  Advertisement Other
Name of person referring (if applicable) :

What are the main concerns you would like orthodontics to accomplish?

Concerns:

Has your child visited an orthodontist before?

Yes No
When: Reason:

Have we treated any other family members?

Yes No
Name:

Have your child's tonsils or adenoids been removed?

Yes No

Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Does your child have any missing or extra permanent teeth?

Yes No

Has your child ever had an injury to (select all that apply):

Teeth Mouth Chin

Does your child have speech problems?

Yes No
If so, explain:

Does your child currently or has your child ever had any of the following habits (check all that apply)?

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

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Medical History

Is your child currently being treated by a physician?

Yes No
Reason: Physician: Last Visit: Phone:

Does your child have any allergies/sensitivities to medications or latex?

Yes No  If yes, please list:

Is your child currently taking any prescription or over-the-counter medications?

Yes No  If yes, please list:

Has your child had any serious illnesses or operations?

Yes No  If yes, please describe:

Has your child ever had a blood transfusion?

Yes No  If yes, give approximate dates:

Is your child pregnant? Yes No

Check if your child has or has ever had any of the following:

Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems

Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia

Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever

Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)

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