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Microsoft word - mi ortho health history child

CONFIDENTIAL CHILD ORTHODONTIC PATIENT QUESTIONNAIRE
PATIENT INFORMATION:
Patient’s Name: ____________________________________________________________________ Sex: M F
Last First MI
Preferred Name: _________________ Birth Date: ____________ Age____ Home Phone: (______)_________________
Address: _____________________________________________________ City: _______________________________ State: ________ Zip: _______________ Patient’s E-mail Address: ___________________________________________ Name of School: ___________________________________________________ Grade Level: ____________________ Hobbies/Interests: __________________________________________________________________________________ Why are you and your child seeking orthodontic treatment? (Please be as specific as possible): _____________________ ________________________________________________________________________________________________ Who referred you to our office? _______________________________________________________________________
FAMILY STATUS:
Father: Mr./Dr.____________________________________________________ Home Phone: (_____)_______________ Address: ______________________________________ City: ____________________ State: ______ Zip:__________ Employer: ___________________________________________ Occupation: __________________________________ Work Phone: (______)_______________ E-Mail Address: _________________________________________________ Cell Phone: (______) _______________ What number would you prefer we use to contact you? ___________________ Mother: Mrs./Ms/Dr._________________________________________________ Home Phone: (______)______________ Address: ______________________________________ City: ____________________ State: ______ Zip:__________ Employer: ___________________________________________ Occupation: __________________________________ Work Phone: (______)_______________ E-Mail Address: _________________________________________________ Cell Phone: (______) _______________ What number would you prefer we use to contact you? ___________________ Marital status of parents: ___________ If divorced, who has custody? ___________ Is the patient adopted? __________ Names and birthdates of patient’s siblings: ______________________________________________________________ _________________________________________________________________________________________________ Responsible Party: Mr./Mrs./Ms./Dr.____________________________________ Home Phone: (_____)_______________
Relationship to Patient: ___________________________ If not a parent, do you have legal guardianship?: ___________ Address: ______________________________________ City: ____________________ State: ______ Zip:__________ Employer: ___________________________________________ Occupation: __________________________________ Work Phone: (______)_______________ E-Mail Address: _________________________________________________ Cell Phone: (______)__________________ What number would you prefer we use to contact you? ________________ INSURANCE INFORMATION: Will you be using dental insurance? ___Yes ___ No If yes, please provide the following:
Primary Subscriber: _____________________________________________ SS# _______________________________ Date of Birth: ______________________ Employer: ______________________________________________________ Insurance Company: ___________________________ Group # ________________ Telephone: (_____)_____________ Secondary Subscriber: ___________________________________________ SS# ______________________________ Date of Birth: ______________________ Employer: ______________________________________________________ Insurance Company: ___________________________ Group # ________________ Telephone: (_____)_____________ (QUESTIONNAIRE CONTINUES ON OTHER SIDE OF SHEET) DENTAL HISTORY:
Patient’s Dentist: _____________________________________________ Phone: (_______) ________________________________ Address: ____________________________________________________________________________________________________ Date of last dental examination and cleaning: _____________________ Drinking water in the home from: __ City __ Well __ Bottled Has this patient ever had previous orthodontic treatment or a consultation? No If yes, when? ________________________ Has another member of the family had orthodontic treatment? No Who?________________________________________ MEDICAL HISTORY:
Family Physician: ________________________________________________ Phone: (_______) ______________________________ Address: ____________________________________________________________________________________________________ Is the patient currently under a physician’s care? No If yes, please explain _______________________________________ Is the patient taking any medicine at this time? No Specify: __________________________________________________ Is the patient currently taking (or has ever taken) any oral or IV bisphosphonate drug (eg. Actonel® (risedronate), Boniva® (ibandronate), Fosamax® (alendronate), Skelid® (tiludronate), Didronel® (etidronate), Aredia® (pamidronate), Zometa® (zolendronic acid), Bonefos® (clodronate)? No If yes, reason: _________________________________________ Is the patient allergic to any medication? No Specify: _____________________________________________________ Does the patient have any other allergies? No Specify: _____________________________________________________ Does the patient have or has the patient ever had any of the following?
Bleeding Disorder Epilepsy/Seizures Injury to Head Oral Ulcers Rheumatic Fever Speech Therapy Previous Surgery
**If the patient has a heart condition, please specify: ________________________________________________________________
Does the patient need to be premedicated (with antibiotics) for routine dental procedures? ___ Yes ___ No If yes, reason: ________________________________________________________________________________________ Does the patient have any other disease, condition, or problem not listed above? Please explain: _____________________________ ___________________________________________________________________________________________________________ Doctor’s Notes: ______________________________________________________________________________________________ ___________________________________________________________________________________________________________ DOES/DID THE PATIENT:
No Brush his/her teeth: Often Occasionally Reluctantly No If yes, at what age was the habit discontinued? _________________
PATIENT’S ATTITUDE TOWARD ORTHODONTIC TREATMENT:
The patient’s interest in having treatment is: Excited Willing if necessary Reluctant

BEHAVIOR ASSESSMENT:
Personality (check all that apply): Calm Nervous Quiet Shy Outgoing Uncooperative Cooperative Progress at school when compared to children of the same age: Behind Same level Advanced
GROWTH STATUS:
Females: Has the patient started her menstruation?
Males: Has the patient undergone voice changes?
☺Thank you for your help! We’re excited to get to know you better…. ☺
Signature of the person completing this form:_____________________________________________________________ Relationship to the patient:_____________________________________________ Today’s date:___________________

Source: http://mibraces.com/wp-content/themes/university-orthodontics/custom/pdf/child_patient_form.pdf