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PATIENT INFORMATION - CHILD
Today’s Date _____________________________________________ Referred by ____________________________________________
Child’s Name (Last) __________________________________ ______ (First) _____________________________________ (MI) _______
Sex _______ Age _______ Date of Birth _______________________ Phone (Home) __________________________________________
Address _________________________________________________ Mom Cell______________________ Dad Cell _________________
City ____________________________ State ____ Zip ____________ School Name & City ______________________________________
_______________________________________________________________
DENTAL and ORTHODONTIC HISTORY
(Write NA if not applicable)
Name of Dentist _________________________Phone Number _____________________Location_________________________________
Date of last dental checkup _____________ Date of last dental x-rays ______________ Was all work completed? ___________________
Reason for today’s visit ____________________________________________________________________________________________
 Good
Child’s attitude toward orthodontic treatment and/or braces:
 Concerned
 Indifferent
Has the child seen another orthodontist? _______________________________________________________________________________
Has any member of the family had or been treated for orthodontic problems? __________________________________________________
Please list any injuries to the face, mouth, or teeth of the child ______________________________________________________________
Has the child been informed of any missing or extra permanent teeth? ________________________________________________________
How often does the child brush his/her teeth? ___________________
Floss? ________________________________________________
Please indicate if child has experienced or has problems with any of the following: (If necessary, please explain YES answers below)
YES NO
YES NO


Pain in teeth or gums
 Difficulty in opening mouth wide


Gum disease
 Pain in jaw joints


Loose permanent teeth
 Clicking or popping in jaw joints (near ears)


Sores on lips or mouth
 Jaw locking or slipping out of place




Breathing primarily through the mouth
 Frequent head or neck aches 



Finger sucking or pacifier
age stopped __________
 Unusual reaction to dental treatment  


Grinding teeth
 day
 night
 Problems with speech



Please explain: ___________________________________________________________________________________________________
_______________________________________________________________
CHILD’S MEDICAL HEALTH INFORMATION
Name of physician_______________________________________
Phone Number __________________________________________
Date of last visit with physician _____________________________
Why? _________________________________________________
Has the child ever been hospitalized?
 Yes
 No
Please explain: _________________________________________
Please list any behavioral or developmental disorders _____________________________________________________________________
List any drugs or medications now being taken by the child:
______________________________________________________
Why? _________________________________________________
OVER
Any known allergies?  Yes
 No
If yes, please list _________________________________________________________________
Has the child ever had any of the following? Please check those that apply:
YES NO
YES NO
 AIDS or HIV positive
 Cleft Lip or Palate
 Heart Murmur/Rheum. Fever  Diabetes
 Asthma/Respiratory Disease  Ear Disease
 Arthritis/Joint Disease
  Epilepsy/Seizures
 Blood/Bleeding Disorder
 Eye Disease
 Glandular/Hormonal Disease  Kidney Disease
YES NO
 Heart Disease/Surgery
 Stomach problems/Ulcers
 Hepatitis (Liver Disease)
 Joint Replacement
 Tuberculosis
 Mental/Nervous Disorder
YES NO
 Anemia
 Cancer
 Radiation/Chemotherapy
 Tumors/.Growth

Any other medical concerns? ______________________________________________________________________________________
PARENT’S INFORMATION
Who will pay account? ____________________________________
Relationship to patient ____________________________________
MOTHER, FULL NAME ___________________________________
FATHER, FULL NAME ____________________________________
Email address __________________________________________
Email address ___________________________________________
Address (if diff. than child) _________________________________
Address (if diff. than child) _________________________________
City ___________________________ State _____ Zip __________
City ___________________________ State _____ Zip __________
Phone: Home ___________________ Work ___________________
Phone: Home ___________________ Work ___________________
MOTHER’S EMPLOYMENT
FATHER’S EMPLOYMENT
Occupation _____________________________________________
Occupation _____________________________________________
Employer ______________________________________________
Employer ______________________________________________
Work Address ___________________________________________
Work Address ___________________________________________
City ___________________________ State _____ Zip __________
City ___________________________ State _____ Zip __________
Parent’s Marital Status:
 Married
 Separated
 Divorced
 Widowed
 Single
 Other ____________________________
Please list any siblings of the patient:
Name_____________________________ DOB_______________
Name_____________________________ DOB_______________
Name_____________________________ DOB_______________
Name_____________________________ DOB_______________
DENTAL INSURANCE INFORMATION
Do you have dental insurance?
 Yes
 No
Who is the insured?  Mother  Father  Other ___________
Insurance Company Name _______________________________
Insured’s DOB _________________________________________
Address ______________________________________________
Insured’s SS # or Plan ID # ________________________________
_____________________________________________________
Group or Plan #_________________________________________
1. I authorize release of any insurance information relating to my insurance claims.
2. I authorize payment to be made directly to Dr. Mark L. Hall by my insurance company.
3. I certify that the above information is accurate to the best of my knowledge.
____________________________________________
Signature of Parent or Legal Guardian
________________________________
Relationship to child
____________________
Date