ACQUAINTANCE/HEALTH QUESTIONNAIRE(for children)

Welcome to our office!

In order to better serve you, please complete the following. This information, important for our records and your health, is confidential.

Patient Information

Date: Age:
Last Name: First Name:
Middle Name: Nickname:
Street Address City:
State: Zip Code:
Home Phone: Birthdate:
Social Security#:    
Names of any family members that have visited us before?    
Whom may we thank for referring you?    
Dentist's Name School and Grade:

Custodial Parent or Responsible Party Information

Last Name: First Name:
Middle Name: Marital Status:
Residential Address:      
Street: City:
State: Zip Code:
Mailing Address:      
Street: City:
State: Zip Code:
How long at this address? Home Phone
Work Phone Cell Phone
Email Address: Fax:
Previous Address (if less than 3 years)      
Street: City:
State: Zip Code:
Social Security # Birth Date:
Relationship to Patient Employer
Occupation: No. Years Employed:
Spouse      
Last Name First Name
Middle Name Relationship to Patient:
Employer Occupation
No. Years Employed Social Security#
Work Phone Birthdate:
Email Address: Cell Phone

Orthodontic Insurance Information

Insured's Name Insured's Social Security#
Insurance Company Group No.
Rayroll No. Insurance Co. Address
Phone# Insured's Employer
Do you have dual coverage? If yes:  
Secondary Insurance      
Insured's Name: Insured's Socical Security:
Insurance Company Group No.
Payroll No. Insurance Co. Address
Phone# Insured's Employer

Patient Information

HIV positive Diabetes Hepatitis Contact Lenses
Allergies/Hay Fever Emotional/Psychological Problems Herpes Rheumatic Fever
Anemia Endocrine Problems High Blood Pressure Thyroid Disorder
Artificial Heart Valves Epilepsy Kidney Disorder Tuberculosis
Asthma Frequent Tonsilitis Liver Disease Mononucleosis
Bleeding Problems Glaucoma Neurologic Disorder Bone Disorder
Blood Disorder Heart Disorder Arthritis Heart Murmur
       
Is the patient under the care of a physician for a specific problem?
List any medications your child is currently taking:
List any DRUG ALLERGIES/SENSITIVITIES
Has patient been advised that antibiotics should be taken prior to dental procedures?
Is there a history of serious illness, accident, or operation?

Developmental History

Father's Height Mother's Height
Patient Height Patient Weight
Has patient reached puberty?      
Girls: Has she started menstruation? If so, when?
Boys: Has voice changed? Hair Development?
Was patient obtained through an adoption process?    

Dental/Medical Related History

Has patient ever sucked a thumb or finger? Until what age?
Have patient's tonsils/adenoids been removed? At what age?
Has patient received or been requested to receive speech therapy?    
Have you been informed of any missing or extra permanent teeth?    

Dental History

Dentist (Name and City):
Dental check-ups: Twice a year Once a year Only if Urgent Never
Date of last check-up: Have all recommended dental procedures been completed?
Has patient received an evaluation or treatment in another orthodontic practice?    
If so, please list the orthodontist's name and city:
       

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
   
Can we send you emails with information and events from our office?
 
By submitting this document, I understand that where appropriate, credit bureau reports may be obtained.

Human Verification

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