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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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