Child Form
PATIENT INFORMATION
Patient's Name
Last
First
Middle
Address
Street
City
State
Zip
Phone
Birth date
Age
S.S.N.
E-mail address
School
Grade
Siblings / Children (Names and ages please)
If patient is a minor, give parent's or guardian's name.
How did you hear about our office?
RESPONSIBLE PARTY INFORMATION
Name
Marital Status
Last
First
Middle
Residence
Street
City
State
Zip
Mailing Address
Street
City
State
Zip
How long at this address
Home Phone
Work Phone
Previous Address
(if less than 3 years )
Street
City
State
Zip
Social Security #
Birth date
Relationship to Patient
Employer
Occupation
Number Years Employed
Spouse's Name
Relationship to Patient
Last
First
Middle
Employer
Occupation
Number Years Employed
Social Security #
Birth Date
Work Phone
INSURANCE INFORMATION
Insured's Name
Insured's Social Security #
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance Company Address
Insurance Phone Number
Do you have dual coverage?
Yes
No
Insured's Name
Insured's Social Security #
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance Company Address
Insurance Phone Number
MEDICAL HISTORY
Patient's Physician
Phone Number
Date of Last Visit
YES
NO
YES
NO
Is the patient taking any medication?
Has the patient had any major operations?
Is the patient allergic to any medications?
Has the patient ever been involved in a serious accident?
Does the patient have a history of a major illness?
Has the patient ever had any of the following diseases or medical problems
YES
NO
YES
NO
Abnormal Bleeding / Hemophilia
Hepatitis / Liver Problems
Anemia
Herpes
Arthritis
High Blood Pressure
Asthma or Hayfever
HIV + / AIDS
Bone Disorders
Kidney Problems
Congenital Heart Defect
Nervous Disorders
Diabetes
Pneumonia
Dizziness
Prolonged Bleeding
Epilepsy
Radiation / Chemotherapy
Gastrointestinal Disorders
Rheumatic Fever
Heart Problems
Tuberculosis
Heart Murmur
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
YES
NO
Is the patient presently in any dental pain?
Has the patient ever experienced any unfavorable reaction to dentistry?
Has the patient ever lost or chipped any teeth?
Has the patient had any injuries to face, mouth or teeth?
Is any part of the patient's mouth sensitive to temperature or pressure?
Do the patient's gums bleed when they brush?
Does the patient have any type of thumb or tongue habit?
Is the patient mouth breather?
Has the patient ever seen an orthodontist?
Has anyone in the family received orthodontic treatment?
How did they feel about the result ?
What is the patient's attitude toward orthodontic treatment ?
Does the patient's teeth or jaws ever feel uncomfortable when they awake in the morning?
Is the patient aware of their jaw clicking or popping?
Is the patient aware of clenching their teeth during the day?
Has the patient ever been told that they grind their teeth?
Does the patient have "tension" headaches?
Has the patient ever experienced chronic ringing in their ears ?
Are you aware some appointments will be during school hours?
Barrer & White Orthodontists • 311 Penn Avenue
West Reading, PA 19611 • (610) 376-3956
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