Patient Form – Under 18 - Havener Orthodontics

Please Fill Out Our Form

If you have any questions, please contact our offices at 956-381-8262

Medical Dental History Form Patients Under Age 18

Patient

Patient Name

First

Middle

Last

Prefers To Be Called

Hobbies, Activities

Birth Date

Age

Sex

Male
Female

Social Security Number

School

Grade

Home Address

City, State, Zip

Home Phone

Cell Phone

Parent/Gaurdian

Custodial Parent's Name

Patient Lives With:

mother
father
stepmother
stepfather
other
grandparent(s)

Check all that apply

If Other, What is the Relationship?

Father's Full Name

Father's Title

Mr.
Dr.
Other

If Other

Father's Occupation

Father's Email Address

Father's Address (if different)

Father's Cell Phone (if different)

Father's Home Phone (if different)

Father's Work Phone

Mother's Full Name

Mother's Title

Mrs.
Ms.
Dr.
Other

If Other

Mother's Occupation

Mother's Email Address

Mother's Address (if different)

Mother's Cell Phone (if different)

Mother's Home Phone (if different)

Mother's Work Phone

Patient's Dentist

Address, City, State

Date Last Seen

Reason

Next Appointment Date

General Information

What concerns you about your child's teeth?

What concerns your child about his/her teeth?

How does your child feel about orthodontic treatment?

Why did you select our office?

Does your child play a musical instrument?

Have any other family members been treated in this office?

If yes, please name them:

Financial Responsibility

Who is financially responsible for this account?

Home Address

City, State, Zip

Home Phone

Cell Phone

Social Security Number

Employer

Who will be responsible for bringing the patient to orthodontic appointments?

Dental Insurance

Do you have dental insurance?

Primary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address (If different than above)

Phone (If different than above)

Employer

Insurance company

Group #

ID #

Do you have dual coverage?

Secondary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address (if different than above)

Phone (if different than above)

Employer

Does this policy have orthodontic benefits?

Yes
No
Don't Know

Physician

Patient's Physician

Physician's Phone

Patient Health Information

Does your child take antibiotic pre-medication before any dental procedures?

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

Have you noticed any unusual changes in your child’s face or jaws?

Any other physical problems?

Please explain

Medical History

Now or in the past, has your child had: (Check all that apply)

Emotional, sensory or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Does your child eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Has your child ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?

Has your child had allergies or reactions to any of the following? (check all that apply)

Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances

Other substances (please explain)

Dental History

Now or in the past, has the patient had: (check all that apply)

Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?

How often does your child brush?

How often does your child floss?

Please review your answers before submitting the form.

Phone

Please Fill Out Our Form

If you have any questions, please contact our offices at 956-381-8262

Medical Dental History Form Patients Under Age 18

Patient

Patient Name

First

Middle

Last

Prefers To Be Called

Hobbies, Activities

Birth Date

Age

Sex

Male
Female

Social Security Number

School

Grade

Home Address

City, State, Zip

Home Phone

Cell Phone

Parent/Gaurdian

Custodial Parent's Name

Patient Lives With:

mother
father
stepmother
stepfather
other
grandparent(s)

Check all that apply

If Other, What is the Relationship?

Father's Full Name

Father's Title

Mr.
Dr.
Other

If Other

Father's Occupation

Father's Email Address

Father's Address (if different)

Father's Cell Phone (if different)

Father's Home Phone (if different)

Father's Work Phone

Mother's Full Name

Mother's Title

Mrs.
Ms.
Dr.
Other

If Other

Mother's Occupation

Mother's Email Address

Mother's Address (if different)

Mother's Cell Phone (if different)

Mother's Home Phone (if different)

Mother's Work Phone

Patient's Dentist

Address, City, State

Date Last Seen

Reason

Next Appointment Date

General Information

What concerns you about your child's teeth?

What concerns your child about his/her teeth?

How does your child feel about orthodontic treatment?

Why did you select our office?

Does your child play a musical instrument?

Have any other family members been treated in this office?

If yes, please name them:

Financial Responsibility

Who is financially responsible for this account?

Home Address

City, State, Zip

Home Phone

Cell Phone

Social Security Number

Employer

Who will be responsible for bringing the patient to orthodontic appointments?

Dental Insurance

Do you have dental insurance?

Primary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address (If different than above)

Phone (If different than above)

Employer

Insurance company

Group #

ID #

Do you have dual coverage?

Secondary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address (if different than above)

Phone (if different than above)

Employer

Does this policy have orthodontic benefits?

Yes
No
Don't Know

Physician

Patient's Physician

Physician's Phone

Patient Health Information

Does your child take antibiotic pre-medication before any dental procedures?

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

Have you noticed any unusual changes in your child’s face or jaws?

Any other physical problems?

Please explain

Medical History

Now or in the past, has your child had: (Check all that apply)

Emotional, sensory or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Does your child eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Does your child frequently breathe through his/her mouth?
Has your child ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Has your child ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?

Has your child had allergies or reactions to any of the following? (check all that apply)

Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances

Other substances (please explain)

Dental History

Now or in the past, has the patient had: (check all that apply)

Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?

How often does your child brush?

How often does your child floss?

Please review your answers before submitting the form.

Website