Child Orthodonic Health History

* - required information
If information not available please enter "None" or "Unknown"

Tell Us About Your Child
Today's Date:	12/21/2024
Child's Name:
* Last:
* First:
MI:
Nickname:
	Male Female
SS #:
Child's Birthdate:
Child's Age:
School:
Grade:
Hobbies / Sports:
* Child's Home #:
Child's Home Address:
City:
State:
Zip:

Who Is Accompanying Your Child Today?
Name:
Relation:
Do you have legal custody of this child?	Yes No
* Whom may we Thank for referring you?
List brothers / sisters with age:
General Dentist:
Last Visit Date:
Parent's Marital Status:	Single Married Divorced Widowed Separated

Mother's Information
	Step Mother Guardian
Name:
Birthdate:
Wk #:
Ext:
Hm #:
Employer:
How Long at Current Job:
Job Title:
SS #:
DL #:

Father's Information
	Step Father Guardian
Name:
Birthdate:
Wk #:
Ext:
Hm #:
Employer:
How Long at Current Job:
Job Title:
SS #:
DL #:

Person Responsible for Account
Name:
Relation:
Billing Address:
City:
State:
Zip:
Previous Address:
City:
State:
Zip:
Hm #:
DL #:
Employer:
Wk #:
Ext:
SS #:

Who is responsible for making appointments?
Name:
Wk #:
Ext:
Hm #:

Primary Orthodontic Insurance
Orthodontic Coverage:	Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Policy Owner's Name:
Relation to Patient:
Policy Owner's Birthdate:
SS #:
Policy Owner's Employer:
Secondary Orthodontic Insurance
Orthodontic Coverage:	Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Policy Owner's Name:
Relation to Patient:
Policy Owner's Birthdate:
SS #:
Policy Owner's Employer:

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

Has your child ever been evaluated or had orthodontic treatment before?	Yes No
Have there been any injuries to the face, mouth, teeth or chin?	Yes No
List any musical instruments played:
Have adenoids or tonsils been removed?	Yes No
Has your child been informed of any missing or extra permanent teeth	Yes No
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?	Yes No
Does your child brush his / her teeth daily?	Yes No
Floss his / her teeth daily?	Yes No
Child's Physician:
Phone #:
Date of last visit:
Is your child currently under the care of a physician?	Yes No
Has puberty begun?	Yes No
Has menstruation begun? (Girls)	Yes No
Please describe your child's current physical health:	Good Fair Poor
Please list all drugs that your child is currently taking:

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


Has your child ever had any of the following medical problems?
Abnormal Bleeding Allergies to any Drugs Allergic to Latex / Metals Allergic to Plastic Any Hospital Stays Any Operations Asthma Cancer Congenital Heart Defect Convulsions / Epilepsy	Diabetes Handicaps / Disabilities Hearing Impairment Heart Murmur Hemophilia Hepatitis HIV+ / AIDS Kidney / Liver Problems Rheumatic / Scarlet Fever Tuberculosis (TB)

Please discuss any medical problems that your child has had:

Does/did your child have any of the following habits?
Clenching / Grinding Teeth Lip Sucking / Biting Mouth Breather Nail Biting	Nursing Bottle Habits Speech Problems Thumb / Finger Sucking Tongue Thrust


Neighbor or Relative not living with you.
Name
Phone
Address
City
State
Zip

	I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.

	I authorize the dental staff to perform the necessary dental services my child may need.

	This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

	If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

The Parent or Guardian who accompanies this child is responsible for payment. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

9350 Waukegan Road
Morton Grove, IL 60053
847.470.0850
nscdh@smilesforyou.com