Hoffman Orthodontics

CHILD PATIENT FORM

First Name

Last Name

Preferred Name

Gender:

Male

Female

Phone

Birthdate

Age

School

Address

City

State

Zip Code

Country

Responsible Party Name

Employer

Cell phone

Address

City

State

Zip Code

Country

2nd Responsible Party Name

Employer

Cell phone

Address

City

State

Zip Code

Country

Referred By:

Name of Dentist:

What is the patient's chief concern?:

Last patient visit to dentist?:

What treatment was done?

Is the patient scheduled to return?

Yes

If yes, explain:

Has the patient consulted with another orthodontist?

Yes

If yes, when?

Has the patient received full or partial orthodontics in another office?

Yes

If yes, what?

Has anyone in the family received orthodontic treatment?

Yes

Pleased with the care they received?

Did the patient have a problem with the teeth or gums?

Yes

If yes, please explain:

Has the patient ever complained of jaw clicking, popping, jaw pain, headaches, or neck aches?

Yes

Does the patient have a habit of thumb sucking, clenching or grinding of teeth, or speech problems?

Yes

Does the patient primarily breathe through his or her mouth?

Yes

Has the patient had his or her tonsils or adenoids removed?

Yes

Does the patient play a musical instrument?

Yes

If yes, which ones?

Does the patient play a contact sports?

Yes

If yes, which ones?

Is the patient usually given antibiotics before dental procedures?

Yes

If yes, which ones?

Does the patient have a history of Anemia, Asthma, Diabetes, Rheumatic Fever, Heart Murmur, Heart Problems, Kidney or Liver Disease, Multiple Sclerosis, Behavioral Problems, Hepatitis, Tuberculosis, HIV, AIDS, or other illnesses?

Yes

If yes, explain:

Does the patient have any known drug or food allergies?

Yes

If yes, explain:

Parent concerns about the patient's teeth?

Send

CHILD PATIENT FORM

CONTACT

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