Download Child Form - Guajardo Orthodontics

to the Orthodontist
The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral
health. Please fill out this form completely. The better we communicate, the better we can care for you!
1. Tell Us About Your Child
Today’s Date:
Child’s Name:
Nickname:
Male
School:
Female
Birthdate:
Grade:
Age:
Child’s Home #: (
Hobbies/Sports:
SS#:
)
E-mail Address:
Childs Home Address:
2. Parental Information
Mother
Name:
Stepmother
Guardian
Birthdate:
Employer:
Work #: ( _)
Job Title:
SS#:
Home #: ( )
How long have you been there?
DL#:
Father
Name:
Stepfather
Guardian
Birthdate:
Employer:
Work #: ( _)
Job Title:
SS#:
Home #: ( )
How long have you been there?
DL#:
Who is Accompanying your Child today?
Person responsible for Account:
Relation:
Who referred you?
3. Primary Orthodontic Insurance
Orthodontic Coverage?
Yes
No
Insurance Co. Name:
Insurance Co. Phone #: ( )
Policy Owner’s Name:
Relationship to Patient:
Policy Owner’s Birthdate:
SSN#:
Please give your Insurance card to the receptionist for a copy, thank you!
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in
the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform
any necessary dental services that my child may need during diagnosis and treatment. This office reserves the right to verify the credit status of potential
patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more
credit reporting services.
I will accept responsibility for any bill incurred for Orthodontic treatment.
Signature _____________________ Date: ___________
4. Patient’s Health History
Patient Dentist:
Phone #: ( )
Has the patient had previous orthodontic consultations?
Last Cleaning:
Yes
No
Treatment?
Yes
No
If so please list where:
Present Drugs/Medications:
List any allergies or drug sensitivity:
What are the main concerns that you would like orthodontics to accomplish?
Has your child ever taken Phen-Fen?
Yes
No (Redux or Pondimin) If yes, When?
Have there been any injuries to the face, mouth, teeth or chin?
List any musical instruments played:
Yes
No
Have adenoids or tonsils been removed?
Yes
No
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Does your child brush his/her teeth daily?
Yes
No
Is your child under the care of a physician?
Please describe your child’s current physical health:
Good
Have you ever had any of the following
Diseases/ Medical problems:
Abnormal Bleeding/Hemophilia
ADD/ ADHD
Allergies to Any drugs
Allergic to Latex / Metals
Allergic to Plastic
Any hospital stays
Any operations
Artificial Bones/Joints /Valves
Asthma
Cancer
Congenital Heart Defect
Tuberculosis (TB)
Yes
No
Phone #: ( )
Date of last visit:
Yes No
No
Does your child floss his/her teeth daily?
Child’s Physician:
5.
Yes
Yes No
Convulsions / Epilepsy
Diabetes
Handicaps / Disabilities
Hearing Impairment
Heart Murmur
Hemophilia
Hepatitis
HIV + / AIDS
Kidney / Liver Problems
Lupus
Rheumatic/Scarlet Fever
Please list any serious medical condition(s) that you have ever had:
Fair
6.
Yes No
Yes
No
Poor
Has your child ever experienced any of
the following?
Clenching / Grinding Teeth
Lip Sucking / Biting
Mouth breather
Nail Biting
Yes No
Nursing/ Bottle Habits
Speech Problems
Thumb / Finger sucking
Tongue Thrust
Our office is HIPPA compliant and is committed to meeting or exceeding the
standards of infection control mandated by OSHA, the CDC, and ADA.
Neighbor or Relative not living with you:
Name:
Phone #: (
)
Address:
Thank you for visiting the office of Dr. Guajardo it was a
pleasure seeing you and your child and we look forward to
seeing you again!