ARNSTINE ORTHODONTICS
MEDICAL, DENTAL HISTORY FORM FOR CHILDREN

PATIENT INFORMATION
Name:	Age Sex M F	Date of Birth
Address: City: State: Zip:		Tel #( )
School:	Grade:	Hobbies:
Whom may we thank for referring you to our office?
Father’s Name: Last: First:	Father’s SS#:
Marital Status: Single Married Divorced Widowed Remarried
Address: City: State: Zip:		Home Tel # ( ) Cell Phone #( )
Employed By:	Work Tel #( )	E-mail:
Mother’s Name: Last: First:	Mother’s SS#:
Address: City: State: Zip:		Home Tel # ( ) Cell Phone #( )
Employed By:	Work Tel #:( )	E-mail:
Marital Status: Single Married Divorced Widowed Remarried
If responsible party is other than the patient’s parents, please give information: Not Applicable
Name:	SS#:	Relationship to Patient:
Address: City: State: Zip:		Tel #( )
Siblings Names and Birthdates:

MEDICAL HISTORY

Patient’s Family Physician:
Has your child ever had or does your child have any of the following? Check all that apply
Rheumatic Fever	Hepatitis	Diabetes	Persistent Headaches
Heart Murmur	Ulcers	Neck Pains	Nerve or Brain Disease
High Blood Pressure	Herpes (Any type)	Arthritis (Any type)	Epilepsy
Heart Attack/Stroke	Psoriasis	Mental Health Problems	Bone Disorders
Blood Vessel Disease	Cancer	Migraines	Swollen Glands
Blood Disorder	Sinus Infection	Sleep Apnea	Allergies
AIDS/HIV Infection	Ear Disorder	Gastric Reflux

Is your child allergic to Latex?
Comments
Please list any other significant information about your child’s medical history:

YES / NO
Yes No	Is your child under a physician’s care at present? If Yes, reason:
Yes No	Is your child presently, or has your child ever been under the care of a psychiatrist or psychologist? If yes, describe:
Yes No	Is your child currently taking any medication? If yes, describe:
Yes No	Is your child allergic to any medications? (Eg: aspirin, penicillin, etc.) If yes, what?
Yes No	Has your child ever had any general anesthesia? When?:

	GROWTH AND DEVELOPMENT:
Yes No	Has your child reached adolescent growth?
Yes No	Girls-has monthly cycle started yet? If yes, when:
Yes No	Boys-Has voice changed yet? If so, when:
Yes No	Is the patient adopted? Does the patient know? Yes No
Yes No	Are there any learning disabilities? If yes, explain:
	Patient’s present height:	Expected height of patient:
	Father’s height:	Mother’s height:

DENTAL HISTORY

Your Child’s Dentist Last Visit:

YES / NO

Yes No

Do any of your child’s teeth hurt? If yes, upper right upper left lower right lower left

Yes No

Have any wisdom teeth been removed? How many?

Yes No

Has your child ever had treatment for periodontal disease (gum disease)? If yes, describe:

Yes No

Has your child ever had any previous orthodontic treatment (braces)? If yes, when?
If yes, doctor’s name and address:

Yes No

Have there been any injuries to your child’s mouth or teeth? If yes, describe:

Yes No

Has your child ever had any injury in the head and neck area? If yes, describe:

Yes No

Has your child ever fallen & bumped his/her chin or received a blow to his/her jaws?
If yes, describe:

Yes No

Has your child ever had any surgery in the head or neck area? If yes, describe:

Yes No

Does your child clench or grind his/her teeth? If yes, while sleeping under stress other:

Yes No

Does your child’s jaw muscles ever feel tired? If yes, when:

Yes No

Does your child ever notice soreness, tightness or pain in the muscles around his/her jaws and face?
If yes, describe:

Yes No

Does it hurt for your child to chew? If yes, where does it hurt?

Yes No

Does your child hear clicking (popping) or grating sounds in his/her jaw joints? If yes, please describe:

	Right	Left	Since when?	During what activity?
Clicking:
Grating

Did these joint sounds begin gradually or suddenly? Gradually Suddenly

Yes No

Was there some specific event that started the joint sounds? If yes, describe:

Yes No

Has your child ever experienced difficulty in opening or closing his/her jaws? If yes, describe:

Yes No

Has your child’s jaws ever “locked” closed? If yes, describe:

Yes No

Has your child’s jaws ever “locked” wide open? If yes, describe:

Yes No

Does your child have pain in his/her jaw joint? If yes, Right Left Since when?

Did his/her pain start Gradually or Suddenly

During what activity? Describe nature of pain:

What increases the pain? What decreases the pain?

Does your child have any of the following habits?
Yes No Finger/Thumbsucking	Yes No Gum Chewing
Yes No Lip Biting	Yes No Ice Chewing
Yes No Nail Biting	Yes No Tongue Thrusting

Please describe why you sought this consultation for your child

Has your child ever been treated for this problem before? Yes No If yes, please describe the diagnosis and treatment:
Any information you can give me concerning your child will be appreciated. The more we know about each patient, the more help we can give in managing the orthodontic treatment, both at home and in the office.
I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination. Initials of Responsible Adult: Date:

I have legal authority for the named minor and hereby give permission for the use of photographs and records obtained in the process of examination, treatment and retention to be used for purposes of research, education or publication in professional journals. Initials: Date: You will be required to sign the forms during your visit to our office.