Child Patient Form

Patient Name

You are
MaleFemale

Birth Date

Age

Home address

City

Province

Postal code

Primary Phone number

Email

School

Grade

List of any sports and other activities

Siblings (name and age)

Parent Marital Status
SingleMarriedDivorcedWidowedSignificant Other

Select One
MotherStep MotherGuardianOther

Name

Date of birth

address(if different than child's)

City

Province

Postal Code

Primary Phone number

Secondary Phone number

Employer's name

Occupation

Postal Code
FatherStep FatherGuardianOther

Name

Date of birth

address(if different than child's)

City

Province

Postal Code

Primary Phone number

Secondary Phone number

Employer Name

Occupation

emergency contact name

Phone number

Related to child

Address

City

Province

Postal Code

Person(s) OK to release appointment or medically related information to concerning child

Related to child

Do you have insurance that covers orthodontics?
YesNo

General dentist

Last visit

How did you hear about our Practice?
ADInternetFamily/FriendDentistOther

Name of the person referring

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

Has your child visited an orthodontist before?
YesNo
When ?
Why ?

Have we treated any other family members?
YesNo
Name ?

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)
TeethMouthChin

Does your child have speech problems?
YesNo
If so explain ?

Does your child currently or has your child ever had any of the following habits (check all that apply)?
Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating Problem

Is your child currently being treated by a physician?
YesNo
Reason
Physician
Last Visit
Phone

Does your child have any allergies/sensitivities to medications or latex?
YesNo
If yes, please list ?

Is your child currently taking any prescription or over-the-counter medications?
YesNo
please list, with dosage

Has your child had any serious illnesses or operations? If yes, describe:
Write here

Has your child ever had a blood transfusion?
YesNo
If yes, give approx date

Is your child pregnant?
YesNo

Nursing ?
YesNo

Taking birth control pills ?
YesNo

Check if your child has or has ever had any of the following ?
AnemiaArthritis, RheumatismArtificial Heart 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 RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsilitisTuberculosisUlcerVenereal Disease (STD)

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Date