Child Patient Information

Gender
MaleFemale

Best way to reach during business hours:
HomeCellWork

Other family members have had:
BracesJaw SugeryOther



Do you have orthodontic insurance coverage?
NoYes (please specify)SelfOther

Medical History

Please check any of the following for which the patient has been treated:

ADD or ADHDAnemiaHay FeverStomach ProblemsAsthmaAutismTuberculosisPneumoniaEndocrine (Hormonal)Epilepsy / SeizuresFainting & dizzinessGrowth DisorderHeart MurmurHeart ProblemsHIV / AIDSDiabetesLatex AllergyLiver ProblemsMononucleosisNervous DisordersRheumatic FeverThyroidKidney ProblemsBleeding DisordersBone DisordersHepatitisHearing ProblemsEar AchesEye ProblemsOther

Please answer the following questions:

Dental History

Please answer the following questions:

Is there a history of:

I, the undersigned, certify that I have read and understand the above medical and dental information, have
reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognize that it is my
responsibility to infrom this office. I also give my permission for clinical examination.