Child New Patient Information

Patient Information

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Parent / Guardian Information

Mother's Name:
Address (if different than child's):

Phone Number: homecell

Secondary Phone Number: homecell

Occupation:

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Dental History

General Dentist: Last Visit:

How did you hear about our Practice?

Ad Internet Family/Friend Physician Other
Name of person referring (if applicable) :

What are the main concerns you would like orthodontics to accomplish?

Concerns:

Has your child visited an orthodontist before?

Yes No
When: Reason:

Does your child currently or has your child ever had any of the following habits (check all that apply)?

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

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Medical History

Is your child currently being treated by a physician?

Yes No
Physician: Last Visit:

Is your child currently taking any prescription or over-the-counter medications?

Yes No
Please list, with dosage:

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