Child Medical and Dental History
Kevin Farnsworth Orthodontics
Patient Information
Patient Name
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
This field is required.
Street Address
Street Address
Street Address Line 2
City
State
Postal
Siblings Names / Ages
School
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Parent/Guardian Information
Mother Name
First Name
Last Name
Mother Marital Status
Single
Married
Divorced
Widowed
This field is required.
Mother Preferred Phone
Mother Email
Primary Email
Mother Employer
Father Name
First Name
Last Name
Father Marital Status
Single
Married
Divorced
Widowed
This field is required.
Father Preferred Phone
Father Email
Primary Email
Father Employer
If Applicable: List any other legal guardians of patient (i.e. step-parent, grandparent, etc)
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Financial and Insurance Information
Primary Dental Insurance
Insurance Name
Insurance Phone
Subscriber Name
First Name
Last Name
Subscriber ID
Subscriber SSN
Subscriber DOB
Group Plan
Yes
No
Unsure
This field is required.
Ortho Coverage
Patient/Guardian Signature
Clear
Signature is mandatory.
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Financial and Insurance Information
Secondary Dental Insurance
Insurance Name
Insurance Phone
Subscriber Name
First Name
Last Name
Subscriber ID
Subscriber SSN
Subscriber DOB
Group Plan
Yes
No
Unsure
This field is required.
Ortho Coverage
Patient/Guardian Signature
Clear
Signature is mandatory.
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Dental History
Dentist Name
First Name
Last Name
Location
Street Address
City
State
Last Visit
Reason for last visit
Have you ever had an orthodontic exam and evaluation?
Yes
No
This field is required.
Do you have, or have you had, any of the following?
Clenching/Grinding of teeth
Thumb/Finger sucking habit
Tongue Thrust habit
Lip or Cheek Biting habit
Mouth Breathing
Trouble Breathing through Nose
Unfavourable Reaction
Traumatic Dental Visit
Unusual change to face or bite
Snoring or sleep apnea
Injury to face, mouth, teeth or chin
Speech problems
Jaw joint problems or soreness in TMJ
Chipped teeth
Late erupting or missing adult teeth
Gum disease
Previous orthodontic treatment
This field is required.
Why are you seeking orthodontic treatment (main concern)?
Interested In (please check):
Braces
Clear Braces
Invisalign
Early Treatment/ Expander
Other
This field is required.
How did you hear about us?
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Medical History
Physician Name
First Name
Last Name
Location
Street Address
City
State
Are you currently taking any medications?
Yes
No
This field is required.
If yes, list medication and condition
List all allergies (medication/food/etc.)
Do you premedicate with antibiotics for dental procedures?
Yes
No
This field is required.
Do you have, or have you had, any of the following?
Allergy to latex
Allergy to metal
Allergy to local anesthesia (lidocaine, novacaine, etc.)
Cancer, tumor, radiation treatment, or chemotherapy
Skin problems
Neurological problems, migraines, seizures, epilepsy
Eyes / Ears / Nose / Throat problems
Tonsils/adenoids removed
Genetic or hereditary problems
Endocrine problems, diabetes, thyroid problems
Respiratory problems, asthma, TB
Cardiovascular problems, heart problems, murmurs, blood pressure, heart defect
Gastrointestinal / liver problems, hepatitis
Kidney problems
Musculoskeletal problems, arthritis, injuries
Immunologic problems, influenza, HIV/AIDS
Herpes, syphilis, gonorrhea
Cleft lip / palate
Eating disorders, anorexia, bulimia
Mental health problems, depression
This field is required.
If "Yes" to above questions, please specify
Do you have any medical problem not listed above?
Patient/Guardian Signature
Clear
Signature is mandatory.
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