Child Information
Responsible Party
Mother __ Father__ Grandparent__ Other__ Child’s Name: ________________________________________ Name: Mr. Mrs. Ms __________________________________ Address: ___________________________________________ Birth Date: __________________________________________ __________________________________________________ School: ____________________________Grade:____________ Billing address if different: ____________________________ Sport/Hobbies: _______________________________________ __________________________________________________ Employer: ____________________________ How long: ____ Siblings Name /Age: ___________________________________ Position: __________________________________________ ____________________________________________________ Work #: _______________________ Cell #______________ How did you hear about our office: _______________________ Email: ____________________________________________ Dental Information
Additional Parent Information
Dentist Name: ________________________________________ Mother __ Father__ Grandparent__ Other__ Name: Mr. Mrs. MS ________________________________ Address: __________________________________________ _________________________________________________ Employer: ________________________________________ How long: ________________________________________ Position: _________________________________________ Work #: _______________________ Cell # _____________ Email: ___________________________________________ Where: _____________________ When: __________________ Orthodontic Insurance Information
General Information
Insurance Company Name ________________________ Insurance Company Phone: _______________________ Patient’s attitude toward braces
Wants braces Indifferent to braces Objects to braces Employer: _____________________________________ Dental History Experience
Insured’s Name: ________________________________ Patient brushing history
Insured’s Social: ________________________________ Patient flossing history
Insured’s Date of Birth: __________________________
Once a day Twice a day Other ______________ Company Group #: ______________________________ Medical History
Allergies or reactions to any of the following
Physician: _____________________ Phone: _______ Local anesthetics (Novocaine or Lidocaine): Yes__ No__ Last physical exam: ___________________________ Foods (specify): ____________________________________ Are you or have you ever taken intravenous Bisposphonates for serious bone disorders/cancers, such as Zometa, Aredia, Are you, or have you ever taken oral Bispophonates for osteoporosis, such as Fosama, Actonel, Boniva, Skelid, Didronel? Please list medications and length of time taking them. Listed: ______________________Length of time: _________ Listed: ______________________Length of time: _________ Listed: ______________________Length of time: _________ Listed: ______________________Length of time: _________ General Information
Any family medical condition we should be If so please explain: ______________________________ _______________________________________________ What is your primary concern with your teeth? ____________________________________________________________________
I have read and understand the above questions and the Hippa Privacy Act. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will inform this practice. Signed: ________________________________________________________________ Date Signed: ________________________ (Parent or Guardian if patient is a minor) Signed: ________________________________________________________________ Date Signed: ________________________

Source: http://www.kainegorthodontics.com/Portals/0/ChildHealthHistory_1130.pdf

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