Yardley Ortho New Patient Child Form

Medical Dental History Form
for Patients Under Age 18

Patient

Date

Patient's last name

First name

Middle initial

Prefers to be called

Hobbies, activities

Birth date

Sex

Male

Female

Social Security #

School

Grade

Email address(es)

Home address

City, State, Zip code

Home phone

Cell phone

Parent/Guardian

Custodial parent(s) name(s)

Patient lives with (check all that apply)

Mother

Father

Stepmother

Stepfather

Grandparent(s)

Other

Father's full name

Title

Mr.

Dr.

Other

Occupation

Email address

Address (if different)

Home phone (if different)

Cell phone

Work phone

Mother's full name

Title

Mrs.

Ms.

Dr.

Other

Occupation

Email address

Address (if different)

Home phone (if different)

Cell phone

Work phone

Dentist

Patient's Dentist

Address, City, State

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen:

Name

City, State

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.

Does your child play a musical instrument?

Brother/sister name

age

had orthodontic treatment?

Yes

If yes where?

Brother/sister name

age

had orthodontic treatment?

Yes

If yes where?

Brother/sister name

age

had orthodontic treatment?

Yes

If yes where?

Brother/sister name

age

had orthodontic treatment?

Yes

If yes 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 than page 1)

City, State, Zip

Home phone

Cell phone

Email 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

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes

Don't Know

Secondary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes

Don't Know

Medical Insurance

Policy holder's full name

Insurance company

Physician

Patient's Physician

City, State

Last seen

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen currently:

Name

City, State

Reason

Name

City, State

Reason

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 don't know/understand (dk/u)

Patient Health Information

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

Medication

Taken for

Medication

Taken for

Do your child have (or ever had) a substance abuse problem?

Do your child chew or smoke tobacco?

Have you noticed any unusual changes in your child's face or jaws?

Any other physical problems?

Family Medical History

Have your 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?

How often does your child floss?

Release and Waiver

I authorize the release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company.

Parent/Guardian Signature

Date

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child's medical or dental health.

Parent/Guardian Signature

Date

Medical History Updates or Changes

Changes

Parent/Guardian Signature

Date

Dental Staff Signature

Date

Changes

Parent/Guardian Signature

Date

Dental Staff Signature

Date

Changes

Parent/Guardian Signature

Date

Dental Staff Signature

Date

Name Validation