Child Medical History Form

Patient's Name Patient's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female Other
Parent Name 1 Parent Name 1 First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Parent 1's Cell Phone Number Parent 1's Cell Phone Number - ### - ### ####
Occupation
Employer
Parent Name 2 Parent Name 2 First Last
Parent's cell phone number 2 Parent's cell phone number 2 - ### - ### ####
Parent 2's occupation
Parent 2's employer
Do you have orthodontic coverage on your insurance?

Do you have orthodontic coverage on your insurance? Yes No I'm not sure
Name of general dentist
How did you hear about our office (check all that apply)

How did you hear about our office (check all that apply) Referral by dentist My family were treated here Google Facebook Instagram TikTok Signage Referral from a friend (please include friend's name so that we can thank them)
Name of family doctor
Does the patient have any medical conditions?

Does the patient have any medical conditions? Yes No
If yes, please list them here:
Is the patient taking any medications?

Is the patient taking any medications? No Yes (Please list them here) Yes (Please list them here)
Does the patient have any allergies?

Does the patient have any allergies? No Yes (if yes, please list them here) Yes (if yes, please list them here)

The following questions pertain to your child's dental and orthodontic health
	No	Yes	Third option
Have you ever experienced trauma to the teeth or jaws?	Have you ever experienced trauma to the teeth or jaws?No	Have you ever experienced trauma to the teeth or jaws?Yes	Have you ever experienced trauma to the teeth or jaws?Third option
Do you have problems chewing your food?	Do you have problems chewing your food?No	Do you have problems chewing your food?Yes	Do you have problems chewing your food?Third option
Do you have problems breathing?	Do you have problems breathing?No	Do you have problems breathing?Yes	Do you have problems breathing?Third option
Do you suffer from sleep apnea?	Do you suffer from sleep apnea?No	Do you suffer from sleep apnea?Yes	Do you suffer from sleep apnea?Third option
Do you have frequent headaches or migraines?	Do you have frequent headaches or migraines?No	Do you have frequent headaches or migraines?Yes	Do you have frequent headaches or migraines?Third option
Do you have any joint problems (arthritis)?	Do you have any joint problems (arthritis)?No	Do you have any joint problems (arthritis)?Yes	Do you have any joint problems (arthritis)?Third option
Are you taking hormones or hormone replacement threapy?	Are you taking hormones or hormone replacement threapy?No	Are you taking hormones or hormone replacement threapy?Yes	Are you taking hormones or hormone replacement threapy?Third option
Are you on any arthritis medication?	Are you on any arthritis medication?No	Are you on any arthritis medication?Yes	Are you on any arthritis medication?Third option
Are you on any osteoporosis medication?	Are you on any osteoporosis medication?No	Are you on any osteoporosis medication?Yes	Are you on any osteoporosis medication?Third option
Do you go to the dentist regularly?	Do you go to the dentist regularly?No	Do you go to the dentist regularly?Yes	Do you go to the dentist regularly?Third option
Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?	Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?No	Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?Yes	Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?Third option

Date of last dental visit Date of last dental visit / MM / DD YYYY
I certify that I have answered all the questions thoroughly and completely.

I certify that I have answered all the questions thoroughly and completely. I certify that the above information is correct.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.