Campbell Ortho

Child History Form

We would like to welcome you and your child to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Patient Information

Gender

Dental History

Has your child ever been evaluated for orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth or chin?
Have adenoids or tonsils been removed?
Does your child have any missing or extra permanent teeth?
Does your child brush his/her teeth adequately?
Does your child floss his/her teeth daily?

Has your child ever complained of:

Jaw joint pain?
Popping or Clicking jaw joints?
Tightness in jaw joints?
Jaws tired during meals?
Frequent headaches?

Does any of the following apply to your child?

Clenching or grinding teeth?
Lip sucking or biting?
Mouth breather
Nursing bottle habits?
Thumb or Finger sucking?
Tounge thrust
Nail biting
Speech Problems?

Medical History

Has your child ever had any of the following?

Abnormal Bleeding
Drug Allergies
Laytex Allergy
Metal Allergy
Plastic Allergy
Hospital stays?
Mental disablity
Operations or Surgery
Cancer
Congenital Heart Defect
Diabetes
Hadicap or Disability
Hearing Impairment
ADD or ADHD
Heart Murmur
Hemophilia
HIV or AIDS
Kidney or Liver problems
Rheumatic or Scarlet Fever
Tuberculosis
Heart Valve Replacement

Orthodontic Insurance

Primary Insurance

Secondary Insurance

Legal Guardian Information

Spouse

Parent Information

Father

Mother

Step Mother

Step Father

Signature

The information that I have provided is correct to the best of my knowledge. I understand that it is my responsibility to inform this practice of any changes in my child's medical status. We are sorry that we cannot accept divorce decrees as assignments of responsibility for a child's orthodontic bills. I also understand that this practice reserves the right to verify the credit status (obtain a report) of any potential responsible party.

Human Verification

Please click on the human verification checkbox before submitting your form.