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Patient's Last name _________________________ First name ________________________________ Middle initial ___ Prefers To Be Called ____________________ Hobbies, activities ______________________________________________ Birth date _____________________ Sex: Male School ______________________________ Grade ___________ E-mail address(es) _____________________________ Home address _____________________________________ City, State, Zip code __________________________________ Custodial parent(s) name (s) ________________________________________________________________________________ Patient lives with (check all that apply) other ________________________________________________________________ Father's full name __________________________________________ Title Occupation ____________________________________ Email address _________________________________________ Address (if different) ______________________________________________________________________________________ Home Phone (if different): ( ) - Cell phone ( ) - Work phone ( ) - Mother's full name _______________________________________ Title Occupation ____________________________________ Email address _________________________________________ Address (if different) _____________________________________________________________________________________ Home Phone (if different): ( ) - Cell phone ( ) - Work phone ( ) - Patient’s Dentist _______________________________ Address, City, State ________________________________________ Last seen ___________________ Reason ______________________________________ Next appointment ____________ Other dentists/dental specialists now being seen: Name _____________________________ City, State ________________ Reason _________________________________________________________________________________________________ What concerns you about your child’s teeth? ___________________________________________________________________ What concerns your child about his/her teeth? _________________________________________________________________ How does your child feel about orthodontic treatment? __________________________________________________________ American Association of Orthodontists 2013 Who suggested that your child might need orthodontic treatment? ________________________________________________ Why did you select our office? _______________________________________________________________________________ Describe any previous orthodontic treatment or consultations. ___________________________________________________ Does your child play a musical instrument? ____________________________________________________________________ Brother/sister name age had orthodontic treatment? Brother/sister name age had orthodontic treatment? Brother/sister name age had orthodontic treatment? Brother/sister name age had orthodontic treatment? Have any other family members been treated in this office? Please name them. ____________________________________ Who is financially responsible for this account? ________________________________________________________________ Address (if different from page 1) ______________________________City, State, Zip __________________________________ Home phone ( ) - Cell phone ( ) - E-mail address(es) ___________________________ Social Security # - - Employer: ________________________________________________ Who will be responsible for bringing the patient to orthodontic appointments? Primary policy holder’s full name ________________________________________________ Birth date ___________________ Social Security # - - Relationship to patient _________________________________________________ Address and phone (if not listed above) ________________________________________________________________________ Employer _________________________________ Address _______________________________________________________ Insurance company ____________________________________ Group # ________________ ID # _______________________ Does this policy have orthodontic benefits? Secondary policy holder’s full name ______________________________________________ Birth date ___________________ Social Security # - - Relationship to patient _________________________________________________ Address and phone (if not listed above) ________________________________________________________________________ Employer _________________________________ Address ________________________________________________________ Insurance company _____________________________________ Group # ________________ ID # _______________________ Does this policy have orthodontic benefits? Policy holder’s full name _____________________________________________________________________________________ Insurance company _________________________________________________________________________________________ Patient’s Physician __________________________ City, State _____________________________________________________ Last seen ____________ Reason ________________________________________________ Next appointment ____________ Most recent physical exam ____________________________________________________________________________________ American Association of Orthodontists 2013 Other physicians/health care providers being seen now: Name ________________________________________ City, State __________________________________________________ Reason ____________________________________________________________________________________________________ Name ________________________________________ City, State __________________________________________________ Reason ____________________________________________________________________________________________________ Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u). Has your child had allergies or reactions to any of the following? dk/u Local anesthetics (novocaine, lidocaine, xylocaine) dk/u Birth defects or hereditary problems? dk/u Cancer, tumor, radiation treatment or chemotherapy? dk/u Gonorrhea, syphilis, herpes, sexually transmitted dk/u Hepatitis, jaundice or other liver problems? Now or in the past, has the patient had: dk/u Polio, mononucleosis, tuberculosis, pneumonia? dk/u Erupting teeth very early or very late? dk/u Seizures, fainting spells, neurologic problem? dk/u Primary (baby) teeth removed that were not loose? dk/u Mental health disturbance or depression? dk/u Permanent or extra (supernumerary) teeth removed? dk/u History of eating disorder (anorexia, bulimia)? dk/u Supernumerary (extra) or congenitally missing teeth? dk/u Chipped or injured primary or permanent teeth? dk/u Excessive bleeding or bruising tendency, anemia? dk/u Chest pain, shortness of breath, tire easily, swollen dk/u Heart defects, heart murmur, rheumatic heart disease? dk/u Any teeth treated with root canals or pulpotomies? dk/u Frequent canker sores or cold sores? dk/u Angina, arteriosclerosis, stroke or heart attack? dk/u History of speech problems or speech therapy? dk/u Skin disorder (other than common acne)? dk/u Does your child eat a well-balanced diet? dk/u Mouth breathing habit or snoring at night? dk/u Vision, hearing, or speech problems? dk/u Frequent ear infections, colds, throat infections? dk/u Frequent oral habits (sucking finger, chewing pen, etc.)? dk/u Teeth causing irritation to lip, cheek or gums? dk/u Does your child frequently breathe through his/her dk/u Has your child ever taken intravenous bisphosphonates dk/u Soreness in jaw muscles or face muscles? such as Zometa (zolendromic acid), Aredia dk/u Has your child been treated for “TMJ” or “TMD” (pamidronate) or Didronel (etidronate) for bone disorders dk/u Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva dk/u Any serious trouble associated with previous dental (ibandronate), Skelid (tiludronate) or Didronel dk/u Has your child ever been diagnosed with gum disease or American Association of Orthodontists 2013 Do you think that any of your child’s activities affect his/her face, teeth or jaws? How? __________________________________ List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes. Medication _______________________________ Taken for ___________________________________________________________ Medication _______________________________ Taken for ___________________________________________________________ Medication _______________________________ Taken for ___________________________________________________________ Do you take antibiotic pre-medication before any dental procedures? Does the patient currently have (or ever had) a substance abuse problem? _____________________________________________ Does your child chew or smoke tobacco? _________________________________________________________________________ Have you noticed any unusual changes in your child’s face or jaws? ___________________________________________________ Any other physical problems? ___________________________________________________________________________________ FAMILY MEDICAL HISTORY Have the parents or siblings ever had any of the following health problems? If so, please explain. Bleeding disorders ____________________________________________________________________________________________ Diabetes ____________________________________________________________________________________________________ Arthritis _____________________________________________________________________________________________________ Severe allergies ______________________________________________________________________________________________ Unusual dental problems ______________________________________________________________________________________ Jaw size imbalance ___________________________________________________________________________________________ Other family medical conditions? _______________________________________________________________________________ How often does your child brush? _______________________________________________________________________________ Floss? ______________________________________________________________________________________________________ RELEASE AND WAIVER I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company. Parent/Guardian Signature ____________________________________________________________ Date____________________________ I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.
Parent/Guardian Signature ____________________________________________________________ Date____________________________ MEDICAL HISTORY UPDATES Changes Parent/Guardian Signature ____________________________________________________ Date____________________________ Dental Staff Signature ________________________________________________________ Date____________________________ Changes Parent/Guardian Signature ____________________________________________________ Date____________________________ Dental Staff Signature ________________________________________________________ Date____________________________ Changes Parent/Guardian Signature ____________________________________________________ Date____________________________ American Association of Orthodontists 2013 Dental Staff Signature ________________________________________________________ Date____________________________ American Association of Orthodontists 2012 2013

Source: http://www.koko-ortho.com/Child%20Medical%20History_11Sep2013.pdf