Child New Patient Information

Patient Information

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Parent / Guardian Information

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Dental History

General Dentist
Last Visit

How did you hear about our Practice?

Ad Internet Family or 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 Problems

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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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