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- Our Vision
- Special Kind of Specialist
About Us
Treatment
Patient Education
Invisalign
Forms
Contact

Child Dental and Medical History

Date (mm/dd/yyyy):*

MM slash DD slash YYYY

Name

First Middle Last

Nick Name

Date of Birth:*

MM slash DD slash YYYY

Age

Please enter a number from 1 to 120.

Sex

Male

Female

Address

City

Zip

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:

Married

Separated

Divorced

Child Lives with

Father's Name

Social Security #

Birthdate

MM slash DD slash YYYY

Address (if different from above)

Telephone

Employer Name and Address

Stepfather (if applicable)

Social Security #

Birthdate

MM slash DD slash YYYY

Mother's Name

Social Security #

Birthdate

MM slash DD slash YYYY

Address (if different from above)

Telephone

Employer Name and Address

Stepmother (if applicable)

Social Security #

Birthdate

MM slash DD slash YYYY

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 experiences with or seen another orthodontist?

No

Yes

Name

Name

MEDICAL HISTORY

General Health

Good

Fair

Poor

Height

Weight

Birth defects

Presently under medical care for

Drugs or medications being taken now, including acne medications (drug and dose)

Allergic to what medication

Is pre-medication needed before dental appointments?

Yes

No

Please check yes or no to the following and date:

Adopted Child

Yes

No

Year

Adenoids (removed)

Yes

No

Year

Allergies

Yes

No

Year

Blood/Bleeding Problems

Yes

No

Year

Bone disorder

Yes

No

Year

Diabetes

Yes

No

Year

Ear/nose infections

Yes

No

Year

Emotional

Yes

No

Year

Endocrine disorder

Yes

No

Year

Epilepsy

Yes

No

Year

Fainting Spells

Yes

No

Year

Glaucoma

Yes

No

Year

Heart disorder murmur

Yes

No

Year

Hepatitis

Yes

No

Year

Hospitalized

Yes

No

Year

Hyperactivity

Yes

No

Year

Learning Disability

Yes

No

Year

Liver disorder

Yes

No

Year

Lung disorder

Yes

No

Year

Rheumatic fever Scoliosis

Yes

No

Year

Speech Difficulty

Yes

No

Year

Tonsils (removed)

Yes

No

Year

Turners Syndrome

Yes

No

Year

Venereal disease

Yes

No

Year

Other

Please give any additional information or details where necessary

MATURATION

Have you grown very much in the past year?

Yes

No

How many inches?

Female patients: Monthly Periods?

Yes

No

Started at age

Male Patients: Voice change?

Yes

No

Facial Hair?

Yes

No

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 the patient play a musical instrument?

Thumb sucking

discontinued at the age of

Other habits: lip biting, nail biting specify

Jaw point (TWJ problems)

noise

pain

earaches/ringing

soreness &stiffness

Speech: difficulty in pronunciation

Yes

No

Speech lessons

Yes

No

PATIENT TREATMENT ATTITUDE

Major reason for seeing treatment

How did you become aware of the orthodontic problem?

Questionnaire completed by

relation to patient

LIFESAVING QUESTIONS

Does your child snore?

Yes

No

Does your child wake up tired and unrefreshed?

Yes

No

Is your child a restless sleeper?

Yes

No

Is your child often tired and cranky?

Yes

No

Does your child have large tonsils?

Yes

No

Does your child have a retrusive lower jaw (no chin)?

Yes

No

Does your child have constricted dental arches (crowded teeth)?

Yes

No

Does your child have dark circles under eyes (tired eyes)?

Yes

No

Does your child wet the bed?

Yes

No

Does your child have frequent bad dreams?

Yes

No

Does your child grind their teeth at night?

Yes

No

HOW DID YOU HEAR ABOUT US?

Referring new patients to our office is the highest compliment we can receive. Please take a moment to let us know all the ways you heard about our office. Put a check next to each source that applies, then circle the main reason you selected our office. Thank you!

HOW DID YOU HEAR ABOUT US?

Dentist

Family Member/Sibling

Friends/Co-workers

Building Sign

Advertisement

Internet

College Scholarships

Direct Mail

Office / School Tours

One of Dr. Hinesly's Employees

Other

Other

Name

This field is for validation purposes and should be left unchanged.

Ann Arbor Office
2433 Oak Valley Dr. Suite
#200 Ann Arbor, MI 48103

Call or Text
Phone: 734-769-7600
Email: hineslyortho@hineslyorthodontics.com

Tecumseh
126 Herrick Park Dr.
Tecumseh, MI 49286

Call or Text
Phone: 517-423-6300
Email: hineslyortho@hineslyorthodontics.com

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