“Take a minute to review, print and fill out your child information form

before your first visit to save you time on arrival!”

    PATIENT INFORMATION

    Patient's Name:

    Date:

    Date of Birth:

    Age:

    Sex:

    School:

    Grade:

    Home Address:

    City:

    Postal Code:

    Tel:

    Number of Children in Family:

    Age & Names of Other Children:

    Patient’s Dentist:

    Patient’s Dentist Tel:

    Family Physician:

    Physician Tel:

    Who may we thank for referring you?

    Parent/Guardian’s E-mail:

    Responsible Party 1:

    Relation:

    Home Tel:

    Day Time Tel:

    Tel Type:

    Responsible Party 2:

    Relation:

    Home Tel:

    Day Time Tel:

    Tel Type:

    Person Responsible for Account:

    Do you have an insurance plan that covers orthodontic treatment?

    YesNoUnsure

    MEDICAL HISTORY

    HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?
    Rheumatic Fever

    YesNo

    Tuberculosis

    YesNo

    Diabetes

    YesNo

    Heart Murmur

    YesNo

    H.I.V./A.I.D.S.

    YesNo

    Kidney Disorder

    YesNo

    Mitral Valve Prolapse

    YesNo

    Hepatitis A, B, or C

    YesNo

    Liver Disease

    YesNo

    Heart Disease

    YesNo

    Sexually Transmitted Diseases

    YesNo

    Asthma

    YesNo

    Artificial Heart Valve

    YesNo

    Blood Disease

    YesNo

    Arthritis

    YesNo

    Artificial Joints

    YesNo

    Prolonged Bleeding

    YesNo

    Other

    If you responded YES to any of the above, please give pertinent information:

    Is the child in good health?

    Does the child have any history of major illness and/or operations?

    List any drugs or medication now being taken: Please give reasons:

    List any allergies or drug sensitivities

    Does the child have a tendency to colds?

    Sore Throats?

    Ear Infections?

    Have tonsils or adenoids been removed?

    at what age?

    Has the patient reached puberty? Girls-Has menstruation started?

    YesNo

    Boys-Has voice changed yet?

    YesNo

    DENTAL HISTORY

    Has the child ever been treated for a jaw joint problem, including surgery?

    YesNo

    Please describe:

    Have there been any injuries to the face, mouth or teeth?

    YesNo

    Please describe:

    Has the child ever sucked his/her thumb or finger?

    YesNo

    Until What age:

    Does the child have any speech problems?

    YesNo

    Does the child have frequent canker or cold sores?

    YesNo

    Is the child a mouth breather? While Asleep:

    YesNo

    While Awake:

    YesNo

    Have you been informed of any missing or extra permanent teeth ?

    YesNo

    Has the child ever had a previous orthodontic examination?

    YesNo

    Is the child especially apprehensive toward dental visits?

    YesNo

    Does the child want orthodontic treatment?

    YesNo

    Has any other family member had braces or orthodontic treatments?

    YesNo

    If yes, name of family member if treated in our office:

    When did the child last see the family dentist?

    List any sports, hobbies or musical instruments

    Reason for orthodontic consultation:

    RELEASE OF INFORMATION:I hereby give Dr. J. Daskalogiannakis and/or members of his staff permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.

    Signature of Parent or Guardian:

    Date

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