Patient Name
Address
Town
Zip Code
Gender
MaleFemale
Home Phone
Email Address
Who Referred You?
School
Grade
Birth Date
Birthplace
Dentist's Name
Date Of Last Checkup
Physician's Name
Date Of Last Checkup
Father's Name
Mother's Name
Father's Date Of Birth
Mother's Date Of Birth
Father's Social Security
Mother's Social Security
Father's Employer
Mother's Employer
Father's Work Phone
Father's Cell Phone
Mother's Work Phone
Mother's Cell Phone
Parent's Marital Status
MarriedDivorcedWidowedSeparatedSingle
Are Any Family Members Currently In Treatment?
YesNo
If So, Why?
Currently Wearing Braces?
YesNo
Currently Wearing Retainers?
YesNo
Has An Appliance?
YesNo
Invisalign?
YesNo
Waiting To Begin Treatment?
YesNo
1. What Are The Main Concerns That You Would Like Orthodontics To Accomplish For Your Child?
2. Is Your Child In Good Health?
YesNo
3. Does Your Child Have Regular Medical Examinations?
YesNo
4. Has Your Child Ever Had Any Of The Following? (Please Check)
Allergies To Any Drugs?
5. Does your child require pre-medication for any condition, If so, What?
6. Is there anything else we should know about your child’s general health? Such as allergies to medications, food, Latex, etc
7. Has your child ever had any injuries to the face, mouth, teeth, or chin? If yes, please explain
8. Is your child a mouth-breather or thumb sucker? If yes, please explain
9. Is there a hereditary background that might contribute to your child’s dental problem
YesNo
10. Has your child ever had any pain / tenderness in their jaw joint (TMJ)?
YesNo
11. Other Remarks
12. Please indicate any medications that your child is currently taking
13. Do you have any Orthodontic Dental Insurance?
14. Name Of Dental Insurance Company?
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