Medical History - Child
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We would like to welcome you to our office.  In an effort to provide the best service possible, we ask you to fill out this form as completely as possible.  Thank you for your cooperation.
Patient Information
Patient's name
Date of Birth
MM
/
DD
/
YYYY
Gender
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Street Address, City, Postal code
Home phone
Cell Phone
Email
General Dentist
Last visit to the dentist (months)
Who may we thank for referring you?
Parent Information
Parent 1 - Full Name and title
Address if different than above
Marital status
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Best phone number to be reached
Email
Parent 2 - Full name and title
Address if different from above
Marital Status
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Best phone number to be reached
Email
General Information
School name
Siblings (include age)
Hobbies
Medical History
Is your child under the care of a phyisician? *
Physician's name and contact information
Has puberty begun? *
Has menstruation (period) begun? *
What are the main concerns you would like orthodontics to accomplish? *
Has the patient ever been evaluated for orthodontic treatment? *
Does the patient like their smile? *
If no, please explain
Has the patient had their tonsils and adenoids removed? *
Has the patient ever experienced any jaw joint pain or discomfort (TMJ//TMD?) *
Does the patient have any extra or missing permanent teeth? *
Required
Has the patient ever had an injury to *
Required
Does the patient have any speech problems *
Is the patient allergic to *
Required
If other, please explain
Does the child have (now or in the past) any of the following habits *
Required
Have they now or have they ever had any of the following *
Required
If yes to any of the above please elaborate
List any medical conditions not listed above
Is the patient currently taking any medication *
Please list any medication
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this office of any changes in my medical status.I hereby authorize the release of any information related to my case to my dentist or primary care physician and related to insurance claims. I consent to the examination by the doctor and authorize the taking of photographs and relevant radiographs if required.
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This form was created inside of Midtown Orthodontics.