Download Child Orthodontic Exam Form

ORTHODONTIC CHILD EXAMINATION SHEET
MICHELE C. PATERNO, DMD, MSD
501 MT. LAUREL ROAD
MT. LAUREL, NJ 08054 (856) 722 – 5664
DATE____________________ 20_______
PATIENT’S NAME_______________________________________________________________ NICKNAME______________________ SEX_______
FIRST
LAST
RES. ADDRESS_______________________________________________________ CITY___________________________________ ZIP_____________
BIRTH DATE_______________________ AGE________
HOME PHONE_______________________________
SCHOOL______________________________________________________ GRADE__________
PATIENT’S DENTIST__________________________________________ DENTIST ADDRESS______________________________________________
REFERRED BY____________________________________________________ PHYSICIAN________________________________________________
NAMES AND AGES OF OTHER CHILDREN IN THE FAMILY_______________________________________________________________________
FATHER’S NAME_____________________________________________________ OCCUPATION___________________________________________
EMPLOYED BY_______________________________________________________ BUS. PHONE_____________________________________________
BUS. ADDRESS_______________________________________________________ SOC. SEC. NO.____________________________________________
DENTAL INSURANCE CO. ?___________________________________________ ORTHO COVERAGE________ BIRTH DATE_________________
MOTHER’S NAME____________________________________________________ OCCUPATION____________________________________________
EMPLOYED BY______________________________________________________ BUS. PHONE______________________________________________
BUS. ADDRESS______________________________________________________ SOC. SEC. NO._____________________________________________
DENTAL INSURANCE CO. ?__________________________________________ ORTHO COVERAGE________ BIRTH DATE__________________
MEDICAL/DENTAL HISTORY
DATE OF LAST DENTAL EXAM.
MONTH______________ YEAR_____________
IS PATIENT IN GOOD HEALTH?________________________________________________________________________________ YES ( ) NO ( )
DOES PATIENT HAVE ANY HISTORY OF MAJOR ILLNESS?______________________________________________________ YES ( ) NO ( )
HAS THE PATIENT EVER BEEN UNDER THE CARE OF A PHYSICIAN FOR ILLNESS?_______________________________ YES ( ) NO ( )
PLEASE LIST:_________________________________________________________________________________________________________________
HAVE TONSILS AND ADENOIDS BEEN REMOVED? WHAT AGE?_________________________________________________ YES ( ) NO ( )
LIST ANY DRUGS OF MEDICATIONS NOW BEING TAKEN. GIVE REASONS:______________________________________________________
LIST ANY ALLERGIES OR DRUG SENSITIVITY:_________________________________________________________________________________
WOMEN: ARE YOU PREGNANT?
YES ( ) NO ( )
HAS THERE BEEN ANY INJURIES TO THE FACE, MOUTH OR TEETH?____________________________________________ YES ( ) NO ( )
IS PATIENT A MOUTH BREATHER?_____________________________________________________________________________ YES ( ) NO ( )
IS PATIENT A THUMB OR FINGER SUCKER?____________________________________________________________________ YES ( ) NO ( )
LIST ANY MUSICAL INSTRUMENTS PLAYED:___________________________________________________________________________________
HAS AN ORTHODONTIST BEEN CONSULTED PREVIOUSLY? _____________________________________________________ YES ( ) NO ( )
REASON FOR CONSULTATION_________________________________________________________________________________________________
__________________________________________________________________________________________________
CHECK ANY OF THE FOLLOWING FOR WHICH THE PATIENT HAD/HAS BEEN EXAMINED OR TREATED.
DIABETES ( ) ANEMIA ( ) PROLONGED BLEEDING ( ) PNEUMONIA ( ) EPILEPSY ( ) FAINTING / DIZZINESS ( ) HEART TROUBLE ( )
TUBERCULOSIS ( ) NERVOUS DISORDERS ( ) RHEUMATIS FEVER ( ) KIDNEY INVOLVEMENT ( ) LIVER DISORDER ( ) BONE
DISORDERS ( ) ENDOCRINE PROBLEMS ( ) ASTHMA ( ) HEPATITIS ( ) ACQUIRED IMMUNE DEFICIENCY ( ) VENEREAL DISEASE ( )
________________________________________________________________
SIGNATURE OF PARENT/PATIENT (IF OVER 18)