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Download dental history - Harrison Orthodontics
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PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE Date___________________ Patient’s name _____________________________________________________________________________________ Last First Middle Address __________________________________________________________________________________________ Street City Zip Nickname______________________ Birthdate_______________ Age _________ Sex: ○ Male ○ Female School___________________________ Grade__________ Patient Lives With: ________________________________________ Parent or guardian name _____________________________________________________________________________ Last First, M.I. Dr. Mr. Mrs. Ms. Miss Whom may we thank for referring you to our office? ________________________________________________________ How did you find out about our office? ○ Newsletter ○School Banner (school ______________) ○ YP.com ○ Heritage Park Banner ○ Internet ○ Swim Team ○ Location of Office ○ School Event _______________________________ ○ Other __________________________________ RESPONSIBLE PARTY INFORMATION ○ Single ○ Married ○ Divorced ○ Separated ○ Widowed Name ____________________________________________________________________________________________ Last First, M.I. Dr. Mr. Mrs. Ms. Miss Residence ________________________________________________________________________________________ Street City Zip How long at this address?______ Home phone_________________________ Work phone ______________________________ Cell phone_________________________ Email address ___________________________________________________________ Social Security #_____________________________ Birthdate_________________ Relationship to Patient _________________ Employer_____________________________________ Occupation____________________ No. years employed _____________ Spouse’s Name_____________________________________________ Relationship to Patient ___________________________ Employer_____________________________________ Occupation____________________ No. years employed _____________ Social Security # ___________________________ Birthdate __________________Work Phone___________________ DENTAL INSURANCE INFORMATION Insured’s Name___________________________________________ Insured’s Social Security # __________________________ Insurance Company_________________________ Group No._________________ Identification No. ______________________ Insurance Co. Address_________________________________________________ Phone No. ____________________ Do you have dual coverage? Yes_____ No_____ If yes: Insured’s Name________________________________________ Insured’s Social Security # ______________________ Insurance Company_________________________ Group No._________________ Identification No. ________________ Insurance Co. Address_________________________________________________ Phone No. ____________________ Parent Signature ______________________________________________________________________________________ Date ________________________________________________________________________________________________ Health History on Reverse MEDICAL HISTORY Please circle Yes or No (If Yes, please fill in details) Yes No Is the patient in good health? ______________________________________________________ Yes No Is the patient taking any medication; reason? ________________________________________ Yes No Is the patient allergic to anything or medication? ______________________________________ Yes No History of a major illness or accident? _______________________________________________ Yes No Is the patient under the care of a physician? Why? _____________________________________ Physician name and phone number ________________________________________________ Circle any of the medical conditions below that the patient has had or currently has: Abnormal bleeding/Hemophilia Congenital Heart Defect Hepatitis Pneumonia ADD/ADHD Depression Herpes Prolonged Bleeding Anemia Arthritis Asthma or Hayfever Bone Disorders Cerebral Palsy Cleft Lip/Palate Diabetes Dizziness Epilepsy/Seizures Gastrointestinal Disorders Heart Problems Heart Murmur High Blood Pressure HIV / AIDS Kidney Problems Learning Disability Liver Problems Nervous Disorders Radiation/Chemotherapy Rheumatic Fever Speech/Hearing Transfusions Tuberculosis Tumor or Cancer Are there any medical conditions we have not discussed that you feel we should be aware of? _______________ __________________________________________________________________________________________ Is there anything else Dr. Harrison should know about the patient? _____________________________________ DENTAL HISTORY General Dentist ______________________________________ Date of last cleaning _____________________ What concerns you most about patient’s teeth? ____________________________________________________ What is the patient’s attitude toward receiving orthodontic treatment? ___________________________________ Yes No Has the patient ever had orthodontic treatment? _______________________________________ Yes No Has the patient been informed of any missing or extra permanent teeth? ___________________ Yes No Have there been any injuries to face, mouth, or teeth? __________________________________ Yes No Any type of thumb/finger habit? ____________________________________________________ Yes No Has an orthodontist been consulted previously? If yes, who and when? ____________________ Yes No Does the patient have pain with chewing, yawning, or opening wide? ______________________ Yes No Does patient’s jaw make clicking or popping noise and is there pain associated with these noises? Yes No Does the patient need extra help with instructions? ____________________________________ Yes No Is the patient sensitive or self-conscious about his/her teeth? ____________________________ Yes No Has either parent had orthodontic treatment? Mom______ Dad______ CONSENT I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Michael A. Harrison to perform a complete orthodontic evaluation. I consent to the taking of photographs and any x-rays deemed necessary for Dr. Harrison to provide an accurate appraisal of any orthodontic problem. I understand that there is no charge for these procedures. Signature of Parent/Guardian: ____________________________________________Date: _________________
