Child Form
Patient's Name *
Patient's Name
Gender
Phone
Phone
Patient's Address
Patient's Address
Responsible Party #1 Address
Responsible Party #1 Address
Cell Phone
Cell Phone
Responsible Party #2 Address
Responsible Party #2 Address
Is the patient scheduled to return?
Has the patient had a consultation with another orthodontist?
Has the patient received full or partial orthodontics in another office?
Has anyone in the family received orthodontic treatment?
Did the patient have a problem with the teeth or gums?
Has the patient ever complained of jaw clicking, popping, jaw pain, headaches, or neck aches?
Does the patient have a habit of thumb sucking, clenching or grinding of teeth, or speech problems?
Does the patient primarily breathe through his or her mouth?
Has the patient had his or her tonsils or adenoids removed?
Does the patient play a musical instrument?
Does the patient play a contact sport(s)?
Is the patient usually given antibiotics before dental procedures?
Does the patient have a history of Anemia, Asthma, Diabetes, Rheumatic Fever, Heart Murmur, Heart Problems, Kidney or Liver Disease, Multiple Sclerosis, Behavioral Problems, Hepatitis, Tuberculosis, HIV, AIDS, or other illnesses?
Does the patient have any known drug or food allergies?