New Patient Form | Child | Spannhake Orthodontics

Gender Assigned At Birth

Male

Female

Date of birth

Preferred Pronouns

Home Phone

Cell Phone

Custodial Parent(s) Name(s)

Who Does the Patient Live With?

Parent 1 Information

Parent 1 Full Name

Title

Address (if different)

Home phone (if different)

Cell Phone

Work phone

Parent 2 Information

Parent 2 Full Name

Title

Address (if different)

Home phone (if different)

Cell Phone

Work phone

Last seen

Reason

Next Appointment

OTHER DENTISTS/DENTAL SPECIALISTS NOW BEING SEEN (NAME, CITY, STATE)

WHAT CONCERNS YOU ABOUT YOUR CHILD’S TEETH?

WHAT CONCERNS YOUR CHILD ABOUT HIS/HER TEETH?

HOW DOES YOUR CHILD FEEL ABOUT ORTHODONTIC TREATMENT?

WHO SUGGESTED THAT YOUR CHILD MIGHT NEED ORTHODONTIC TREATMENT?

WHY DID YOU SELECT OUR OFFICE?

DESCRIBE ANY PREVIOUS ORTHODONTIC TREATMENT OR CONSULTATIONS.

DOES YOUR CHILD PLAY A MUSICAL INSTRUMENT?

Brother/sister #1 Name

Age

Had Orthodontic Treatment

Yes

If Yes, Where?

Brother/sister #2 Name

Age

Had Orthodontic Treatment

Yes

If Yes, Where?

Brother/sister #3 Name

Age

Had Orthodontic Treatment

Yes

If Yes, Where?

Brother/sister #4 Name

Age

Had Orthodontic Treatment

Yes

If Yes, Where?

HAVE ANY OTHER FAMILY MEMBERS BEEN TREATED IN THIS OFFICE? PLEASE NAME THEM?

Financial Responsibility

WHO IS FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT?

ADDRESS (IF DIFFERENT)

Home Phone (If Different)

Cell Phone

WHO WILL BE RESPONSIBLE FOR BRINGING THE PATIENT TO ORTHODONTIC APPOINTMENTS?

PRIMARY POLICY HOLDER’S FULL NAME

Birthdate

SSN#

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

DOES THIS POLICY HAVE ORTHODONTIC BENEFITS?

SECONDARY POLICY HOLDER’S FULL NAME

Birthdate

SSN#

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

DOES THIS POLICY HAVE ORTHODONTIC BENEFITS?

POLICY HOLDER’S FULL NAME

Patients Physician

City

State

Last seen

Reason

Next Appointment

Most recent physical exam

Other physicians/health care providers being seen now:

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (DKU).

Now or in the past, has your child had:

BIRTH DEFECTS OR HEREDITARY PROBLEMS?

Yes

Don't Know

BONE FRACTURES, OR MAJOR INJURIES?

Yes

Don't Know

ANY INJURIES TO FACE, HEAD, NECK?

Yes

Don't Know

ARTHRITIS OR JOINT PROBLEMS?

Yes

Don't Know

CANCER, TUMOR, RADIATION TREATMENT OR CHEMOTHERAPY?

Yes

Don't Know

ENDOCRINE OR THYROID PROBLEMS?

Yes

Don't Know

DIABETES OR LOW SUGAR?

Yes

Don't Know

KIDNEY PROBLEMS?

Yes

Don't Know

IMMUNE SYSTEM PROBLEMS?

Yes

Don't Know

STOMACH ULCER, HYPERACIDITY, ACID REFLUX?

Yes

Don't Know

HISTORY OF OSTEOPOROSIS?

Yes

Don't Know

GONORRHEA, SYPHILIS, HERPES, SEXUALLY TRANSMITTED DISEASES?

Yes

Don't Know

AIDS OR HIV POSITIVE?

Yes

Don't Know

HEPATITIS, JAUNDICE OR OTHER LIVER PROBLEMS?

Yes

Don't Know

POLIO, MONONUCLEOSIS, TUBERCULOSIS, PNEUMONIA?

Yes

Don't Know

SEIZURES, FAINTING SPELLS, NEUROLOGIC PROBLEM?

Yes

Don't Know

MENTAL HEALTH DISTURBANCE OR DEPRESSION?

Yes

Don't Know

HISTORY OF EATING DISORDER (ANOREXIA, BULIMIA)?

Yes

Don't Know

FREQUENT HEADACHES OR MIGRAINES?

Yes

Don't Know

HIGH OR LOW BLOOD PRESSURE?

Yes

Don't Know

EXCESSIVE BLEEDING OR BRUISING TENDENCY, ANEMIA?

Yes

Don't Know

CHEST PAIN, SHORTNESS OF BREATH, TIRE EASILY, SWOLLEN ANKLES?

Yes

Don't Know

HEART DEFECTS, HEART MURMUR, RHEUMATIC HEART DISEASE?

Yes

Don't Know

ANGINA, ARTERIOSCLEROSIS, STROKE OR HEART ATTACK?

Yes

Don't Know

SKIN DISORDER (OTHER THAN COMMON ACNE)?

Yes

Don't Know

DO YOU EAT A WELL-BALANCED DIET?

Yes

Don't Know

VISION, HEARING, OR SPEECH PROBLEMS?

Yes

Don't Know

FREQUENT EAR INFECTIONS, COLDS, THROAT INFECTIONS?

Yes

Don't Know

ASTHMA, SINUS PROBLEMS, HAYFEVER?

Yes

Don't Know

TONSIL OR ADENOID CONDITION?

Yes

Don't Know

DOES YOUR CHILD FREQUENTLY BREATHE THROUGH YOUR MOUTH?

Yes

Don't Know

HAS YOUR CHILD EVER TAKEN INTRAVENOUS BISPHOSPHONATES SUCH AS ZOMETA (ZOLENDROMIC ACID), AREDIA (PAMIDRONATE) OR DIDRONEL (ETIDRONATE) FOR BONE DISORDERS OR CANCER?

Yes

Don't Know

HAS YOUR CHILD EVER TAKEN ORAL BISPHOSPHONATES SUCH AS FOSAMAX (ALENDRONATE), ACTONEL (RIDENDRONATE), BONIVA (IBANDRONATE), SKELID (TILUDRONATE) OR DIDRONEL (ETIDRONATE) FOR BONE DISORDERS?

Yes

Don't Know

Has your child had allergies or reactions to any of the following?

LOCAL ANESTHETICS (NOVOCAINE, LIDOCAINE, XYLOCAINE)

Yes

Don't Know

LATEX (GLOVES, BALLOONS)

Yes

Don't Know

ASPIRIN

Yes

Don't Know

IBUPROFIN (MOTRIN, ADVIL)

Yes

Don't Know

PENICILLIN

Yes

Don't Know

OTHER ANTIBIOTICS

Yes

Don't Know

METALS (JEWELRY, CLOTHING SNAPS)

Yes

Don't Know

ACRYLICS

Yes

Don't Know

PLANT POLLENS

Yes

Don't Know

ANIMALS

Yes

Don't Know

FOODS

Yes

Don't Know

OTHER SUBSTANCES

Yes

Don't Know

Now or in the past, has the patient had:

ERUPTING TEETH VERY EARLY OR VERY LATE?

Yes

Don't Know

PRIMARY (BABY) TEETH REMOVED THAT WERE NOT LOOSE?

Yes

Don't Know

PERMANENT OR EXTRA (SUPERNUMERARY) TEETH REMOVED?

Yes

Don't Know

SUPERNUMERARY (EXTRA) OR CONGENITALLY MISSING TEETH?

Yes

Don't Know

CHIPPED OR INJURED PRIMARY OR PERMANENT TEETH?

Yes

Don't Know

ANY SENSITIVE OR SORE TEETH?

Yes

Don't Know

ANY LOST OR BROKEN FILLINGS?

Yes

Don't Know

JAW FRACTURES, CYSTS, INFECTIONS?

Yes

Don't Know

ANY TEETH TREATED WITH ROOT CANALS OR PULPOTOMIES?

Yes

Don't Know

FREQUENT CANKER SORES OR COLD SORES?

Yes

Don't Know

HISTORY OF SPEECH PROBLEMS OR SPEECH THERAPY?

Yes

Don't Know

DIFFICULTY BREATHING THROUGH NOSE?

Yes

Don't Know

MOUTH BREATHING HABIT OR SNORING AT NIGHT?

Yes

Don't Know

HISTORY OF SPEECH PROBLEMS?

Yes

Don't Know

FREQUENT ORAL HABITS (SUCKING FINGER, CHEWING PEN, ETC.)?

Yes

Don't Know

TEETH CAUSING IRRITATION TO LIP, CHEEK OR GUMS?

Yes

Don't Know

TOOTH GRINDING OR CLENCHING?

Yes

Don't Know

CLICKING, LOCKING IN JAW JOINTS?

Yes

Don't Know

SORENESS IN JAW MUSCLES OR FACE MUSCLES?

Yes

Don't Know

HAS YOUR CHILD BEEN TREATED FOR “TMJ” OR “TMD” PROBLEMS?

Yes

Don't Know

ANY BROKEN OR MISSING FILLINGS?

Yes

Don't Know

ANY SERIOUS TROUBLE ASSOCIATED WITH PREVIOUS DENTAL TREATMENT?

Yes

Don't Know

HAS YOUR CHILD EVER BEEN DIAGNOSED WITH GUM DISEASE OR PYORRHEA?

Yes

Don't Know

Patient Health Information

DO YOU THINK THAT ANY OF YOUR CHILD’S ACTIVITIES AFFECT HIS/HER FACE, TEETH OR JAWS? HOW?

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.

Medication

Taken for

Medication

Taken for

Medication

Taken for

DOES THE PATIENT CURRENTLY HAVE (OR EVER HAD) A SUBSTANCE ABUSE PROBLEM?

DOES YOUR CHILD CHEW OR SMOKE TOBACCO?

HAVE YOU NOTICED ANY UNUSUAL CHANGES IN YOUR CHILD’S FACE OR JAWS?

ANY OTHER PHYSICAL PROBLEMS?

Family Medical History

HAVE THE PARENTS OR SIBLINGS EVER HAD ANY OF THE FOLLOWING HEALTH PROBLEMS? IF SO, PLEASE EXPLAIN.

Have the parents or siblings ever had any of the following health problems? If so, please explain.

UNUSUAL DENTAL PROBLEMS

OTHER FAMILY MEDICAL CONDITIONS?

HOW OFTEN DOES YOUR CHILD BRUSH?

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

PARENT/GUARDIAN SIGNATURE

Date

I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.

Medical Dental History Form for Patients Under Age 18