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Your Child's Information

If Minor

YesNoHas the patient received previous orthodontic consultation?

YesNoDo you have any other family members in our practice?

Responsible Party Information

YesNoDo you have orthodontist insurance?
Insurance Information
Primary Insurance

Secondary Insurance

Medical History
YesNoIs patient having any dental pain or discomfort?
YesNoHas patient had habit of thumb or finger sucking
YesNoAre they currently under physicians care?
YesNoAre they taking any medications?
YesNoAre they allergic to any medications, food, latex?
YesNoDo they take any medications prior to dental treatment?
YesNoHave they ever had any excessive bleeding requiring special treatment?
YesNoHave they ever had any trauma
YesNoDoes anyone in your family had orthodontic treatment that has caused root resorption?
YesNoDo you have any disease, condition, or problem not listed?
YesNoHave they had their first menstrual cycle?
YesNoAre they pregnant now?
YesNoDo they anticipate becoming pregnant?
YesNoHas their voice changed?
YesNoDoes your child breath through their mouth?
YesNoDoes your child snore when they are asleep?
YesNoDoes your child sleep with their mouth open?
YesNoHas your child had their tonsils and adenoids taken out?
Check any of the following which they have had or have at present:
Heart Failure
Heart Disease or Attack
HIV Positive
Angina Pectoris
Tuberculosis (TB)
Hepatitis A (infectious)
High Blood Pressure
Hepatitis B (serum)
Heart Murmur
Hay Fever
Liver Disease
Heart Surgery
Sinus Trouble
Rheumatic Fever
Congenital Heart Lesions
Blood Transfusion
Drug Addiction
Mitral Valve Prolapse
Venereal Disease (Syphilis, Gonorrhea)
Thyroid Disease
Cold Sores
Allergies or Hives
Artificial Heart Valve
X-Ray or Cobalt Treatment
Genital Herpes
Artificial Joint
Epilepsy or Seizures
Pain in Jaw Joints
Fainting or Dizzy Spells
Bruise Easily
Kidney Trouble
Psychiatric Treatment
Sickle Cell Disease
Scarlet Fever

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or change in medications, I will inform the office and doctor at the next appointment without fail.

I give my permission to disclose any treatment and financial information to whomever brings my child to their appointment.

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