Child New Medical History Form

Patient's Last Name	First Name	Middle

Patient's E-Mail Address :
Preferred to be called	Sex

Home Address

City	State	Zip

Patient Resides With	Mother	Father
Patient Resides With	Both	Other

Home Phone	Age	Birth date

School	Grade

Phone Number to Reach Someone During the Day

Please describe your child's orthodontic
problem in your own words

Patients Interests

Your child's general dentist's name	Referred By

Names and Ages of patient's brothers and sisters

Has anyone in the family had braces? YES NO

with whom:

Date of last dental exam:

Parents Maritial Status	Married	Widowed
	Separated	Single
	Divorced	Remarried

Parents and Account Information

Father

Name

Address
City, State, Zip ,

Phone

SSN

Employer's Name

Business Address
City, State, Zip ,

Business Phone

Occupation

Mother

Name

Address
City, State, Zip ,

Phone

SSN

Employer's Name

Business Address
City State, Zip

Business Phone

Occupation

Other Responsible Person

Name

Address
City, State, Zip ,

Phone

Medical History

Physician's Name

Address
City, State, Zip ,

Phone

YES

Has your child experienced any health problems?

Explain :

Any major change in your child's health recently?

Explain :

Is your child currently under a physicians care?

Explain :

Is your child currently taking medications?

Explain :

Is your child allergic to any medications?

Explain :

Has your child received a blood transfusion?

Explain :

Have your child's tonsils or adenoids been removed

Explain :

Has your child been in a risk group for AIDS?

Explain :

Does your child require antibiotics before dental TX

Explain :

Please check if your child has had any of the following conditions:

YES

Heart Murmur

Heart Surgery

Developmental Disorder

Asthma

Hepatitis

Diabetes

Tuberculosis

Growth Disorders

Emotional Problems

Frequent Headaches

Bone Disorders

Mouth Breather

Is there any condition or problem
that you think we should know about?

Comments:

Dental History

Frequency of Dental Checkups	Twice a year
	Once a year
	Only if a problem exists

	NO	YES
Is there any unfinished care to be completed with your child's dentist?
Explain:
Has your child had any face or dental injuries?
Explain :
Is there a history of thumb or finger sucking?
Stopped?
Does your child play any musical instrument?
What instrument?
Has your child consulted an orthodontist previously?
With whom?
Have teeth (either primary or permanent) been removed?

Has your child had any previous orthodontic treatment?
With whom?
Is there any other information that may be helpful?

Insurance Information

Do you have orthodontic insurance : YES NO

A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the patients account and the patient or person responsible for the account is responsible for payment of all fees incurred. For your convenience, we will gladly assist you in submitting insurance claim forms from your insurance carrier pertaining to any charge for care in our office. If you wish assistance, we ask that you provide us with claim forms to your insurance carrier on your first visit. Otherwise we will assume you are submitting all claims to your insurance carrier. We will accept assignment of benefits from your insurance company if possible.

Name of insured : (employee)
SS#
Date of Birth
Name of insurance Company
Group #

Name of insured : (employee)
SS#
Date of Birth
Name of insurance company
Group #

Successful orthodontic treatment is achieved with excellent communication and personalized attention. In an effort to address your orthodontic concerns please indicate below what you would like orthodontics to accomplish for you:
	Enhance aesthetics and appearance	Increase self-confidence
	Create Facial balance	Enhance overall dental health
	Improve Function and comfort	Avoid Future problems
What specific questions would you like answered?

7729 79th Street South - Cottage Grove, MN 55016 - Phone: 651.459.6674 -
e-mail: info@orthodonticsbyhipple.com - www.orthodonticsbyhipple.com
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