Child Form | Orland Park IL | Damas Orthodontics

Responsible Party Information

Date

Name of Responsible Party

Last

First

Middle

Address (Street, City, State, Zip)

How long at this address

Previous Address (if less than 3 years at current):

SSN#

Birth Date

Relationship to Patient

Email address we can use for appointment reminders

Employer

Occupation

# of years employed

Spuse's Name

Last

First

Middle

Relationship to Patient

Employer

Occupation

# of years employed

Responsible Party Information

Patient Name

Last

First

Middle

Birth date

Age

Gender

Male

Female

SSN#

If patient is a minor, give parent's or guardian's name(s)

If the patient has siblings, please give the sibling's name(s)

Home phone

Whom may we thank for referring you to our office?

Insurance Information

Policy Holder

Last

First

Middle

#SSN

Insurance Company

ID Number

Union Local Number

Insurance Address

Insurance Phone #

Policy Holder's Employer

Do You Have Dual Coverage?

Yes

No

If yes, please fill out the following

Policy Holder

Last

First

Middle

#SSN

Insurance Company

ID Number

Union Local Number

Insurance Address

Insurance Phone #

Policy Holder's Employer

Emergency Contact Information

Name of nearest relative not living with you:

Address of Relative

Phone

Relationship

Dental and Medical History

What are the main concerns that you would like orthodontics to accomplish?

Name of your child's general dentist

Phone

Answer yes if applicable now or in the past:

Any past orthodontic evaluations, consultations or treatment

Yes

No

If yes, when?

Any injuries to face, mouth, teeth

Yes

No

Plays a musical instrument

Yes

No

If yes, what instrument?

Tonsils/Adenoids removed

Yes

No

Been informed of any missing or extra permanent teeth

Yes

No

Jaw joint pain or tenderness

Yes

No

Floss his/her teeth daily

Yes

No

Is your child currently under the care of a physician

Yes

No

If yes..

Physician name

Phone

Date of last visit

Has your child begun puberty

Yes

No

If patient is a girl, has menstruation begun

Yes

No

Please describe your child's current physical health

Good

Fair

Poor

Please list all drugs/medications that your child is currently taking

Please list all drugs/things that your child is allergic to

Other allergies

Latex

Yes

No

Metals/Nickel

Yes

No

Plastics

Yes

No

Has your child had any of the following medical conditions?

Abnormal bleeding

Yes

No

ADD / ADHD

Yes

No

Any hospital stays or surgical operations

Yes

No

Heart murmurs

Yes

No

Artificial joints, bones, or valves

Yes

No

Hepatitis

Yes

No

HIV / AIDS

Yes

No

Kidney or liver problems

Yes

No

Rheumatic / Scarlet fever

Yes

No

Convulsions / Epilepsy

Yes

No

Diabetes

Yes

No

Handicaps / Disabilities

Yes

No

Hemophilia

Yes

No

Asthma

Yes

No

Cancer

Yes

No

Congenital Heart Defect

Yes

No

Lupus

Yes

No

Tuberculosis

Yes

No

Has your child ever experienced any of the following?

Clenching / Grinding teeth

Yes

No

Nursing bottle habits

Yes

No

Mouth Breather

Yes

No

Nail Biting

Yes

No

Speech Problems

Yes

No

Lip Sucking / Biting

Yes

No

Thumb / Finger Sucking

Yes

No

Tongue Thrust

Yes

No

Other:

If you checked yes to any of the above, please explain

Signature of Parent/Guardian

Date

Confidential Youth Patient Health History Form

Office Locations