CHILD DENTAL AND MEDICAL HISTORY
Date
first name
last name
middle name
Date of Birth
Age
Sex
Nickname
Address
City
State
Zipcode
Phone (Home/Cell)
Email
Work phone-Mom
Work phone-Dad
Family Dentist
City
Phone
Family physician
City
Phone
School
City
Grade
Sports/ Hobbies etc.
Family History
Parents
Divorced
Separated
Married
Child Lives with
Father’s name
Social Security #
Birthdate
Address (if different from above)
Telephone
Employer Name
Employer Address
Stepfather (if applicable)
Social Security #
Birthdate
Mother’s name
Social Security #
Birthdate
Address (if different from above)
Telephone
Employer Name
Employer Address
Stepmother (if applicable)
Social Security #
Birthdate
Names and ages of brothers and sisters
Other family members with similar dental conditions (names and ages)
Other family members with orthodontic treatment (including parents)
Have you had any other experience with or see another orthodontist? If yes, who?
Medical History
General Health
Poor
Fair
Good
Height
Weight
Presently under medical care for
Birth defects
Medications currently being taken, including acne medications (drug and dose)
Allergic to what medication
Is pre-medication needed before detail appointments?
No
Yes
Please check yes or no to the following and date:
Adopted Child
No
Yes
Year
Adenoids (removed)
No
Yes
Year
Allergies
No
Yes
Year
Blood/Bleeding Problems
No
Yes
Year
Ear/nose infections
No
Yes
Year
Emotional
No
Yes
Year
Endocrine disorder
No
Yes
Year
Fainting Spells
No
Yes
Year
Glaucoma
No
Yes
Year
Heart disorder murmur
No
Yes
Year
Hepatitis
No
Yes
Year
Hospitalized
No
Yes
Year
Learning disorder
No
Yes
Year
Liver disorder
No
Yes
Year
Lung disorder
No
Yes
Year
Rheumatic fever Scoliosis
No
Yes
Year
Speech difficulty
No
Yes
Year
Tonsils (removed)
No
Yes
Year
Tumers Syndrome
No
Yes
Year
Venereal disease
No
Yes
Year
Additional information or details regarding medical issues
Maturation
Have you grown very much in the past year?
No
Yes
How many inches?
Female patients
Monthy Periods?
No
Yes
Started at age
Male patients
Voice change?
No
Yes
Facial Hair?
No
Yes
Other indications of pubertal development
Dental History
Date of last dental check-up
Injury or trauma to the face or teeth
Brushing teeth: Several times per day, once a day, rarely?
Does this patient play a musical instrument?
Speech: difficulty in pronunciation
No
Yes
Speech lessons
No
Yes
Thumb sucking, discontinued at the age of:
Does your jaw cause noise, pain, earaches/ringing, soreness & stiffness?
Other habits: lip biting, nail biting, specify
Patient Treatment Attitude
Major reason for seeking treatment
How did you become aware of the orthodontic problem?
Questionnaire completed by, relation to patient
Lifesaving Questions
Does your child snore
No
Yes
Does your child wake up tired and unrefreshed
No
Yes
Is your child a restless sleeper
No
Yes
Does your child have large tonsils
No
Yes
Does your child have a retrusive lower jaw (no chin)
No
Yes
Does your child have constricted dental arches (crowded teeth)
No
Yes
Does your child have dark circles under eye (tired eyes)
No
Yes
Does your child wet the bed
No
Yes
Does your child have frequent bad dreams
No
Yes
Does your child grind their teeth at night
No
Yes
How did you hear about us?
Select all that apply. Thank you!
Dentist
No
Yes
Building Sign
No
Yes
College scholarships
No
Yes
One of Dr. Hinesly’s Employees
No
Yes
Family Member/ Sibling
No
Yes
Advertisement
No
Yes
Direct Mail
No
Yes
Friends/Co-Workers
No
Yes
Internet
No
Yes
Office/School Tours
No
Yes
Other
No
Yes
Which of the above is the main reason you selected our office?
