Fillable Np Boy Hh Info Form

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Np Boy Hh Info Form

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File type: PDF

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CHILD PATIENT INFORMATION - MALE
P
atient’s Name (First, Middle, Last) ______________________________________________________Age____________Birthdate_____________
Nickname (if preferred) __________________________________________ Patient’s Home Phone ______________________________________
Patient’s Home Address_________________________________________________ City, State, Zip_____________________________________
School name ______________________________________________________________________ Grade _______________________________
How did you hear about our office? __________________________________________________________________________________________
Has your child visited an orthodontist before or had any previous treatment? O Yes O No If Yes, please explain? _________________________
______________________________________________________________________________________________________________________
Have we treated another member of your family? O Yes O No If Yes, Name (First, Last) _____________________________________________
Siblings (Name, Age) ____________________________________________________________________________________________________
PARENTS/GUARDIAN INFORMATION
P
atient Lives With: O Father O Mother O Step-Father O Step-mother O Grandfather O Grandmother O Aunt O Uncle O Guardian O Other
Name (First, Last) _________________________________________________________ Relationship ___________________________________
Address (Street, City, State, Zip) ____________________________________________________________________________________________
Home # _____________________________ Cell #________________________________ Email ________________________________________
Driver’s Lic # ____________________________________________ Social Security # _________________________________________________
Employer _____________________________________________________________ Work # __________________________________________
Name (First, Last) _________________________________________________________ Relationship ___________________________________
Address (Street, City, State, Zip) ____________________________________________________________________________________________
Home # _____________________________ Cell #________________________________ Email ________________________________________
Driver’s Lic # ____________________________________________ Social Security # _________________________________________________
Employer _____________________________________________________________ Work # __________________________________________
If you have DENTAL insurance coverage for the child, please fill out.
Insured Name (First, Last) _________________________________________________________________________________________________
Relationship to Patient ________________________Social Security Number ____________________________ Date of Birth _________________
Employer ____________________________________________ Employer Address __________________________________________________
Insurance Company ________________________________________ Group # _____________________________ ID # _____________________
Insurance Company Address _______________________________________________ Phone Number __________________________________
EMERGENCY INFORMATION
Name of nearest relative not living with you (First, Last) __________________________________ Relationship _____________________________
Address (Street, City, State, Zip) ____________________________________________________ Phone # ________________________________
DENTAL HISTORY
Patient’s General Dentist Name ________________________________________________ Date of last cleaning___________________________
Dentist address _______________________________________________________ Phone number _____________________________________
Does the child require pre-medication antibiotics before dental treatment? O Yes O No If Yes, explain __________________________________
Have the adenoids or tonsils been removed? O Yes O No Have you been informed of any missing or extra permanent teeth? O Yes O No
Any injuries to the child’s face, mouth or chin? O Yes O No Has the child ever had pain/tenderness in the jaw joint (TMJ/TMD)? O Yes O No
Does the child play a musical instrument? O Yes O No If Yes, what kind? ________________________________________________________
Does/Did the child have any of the following?
O Unfavorable Dental experience O Clenching or Grinding O Finger/Thumb Sucking
O Prolonged Bottle/Pacifier O Mouth Breathing O Speech Problems
O Chewing/Eating Problems O Tongue Thrust O Teeth sensitivity
MEDICAL HISTORY
Is the child currently under the care of a physician? O Yes O No If Yes, for what reason? ____________________________________________
Child’s Physician _________________________________________________________ Phone number __________________________________
History of major illness or Medical condition? O Yes O No If Yes, please describe__________________________________________________
Currently taking any medication? O Yes O No If Yes, please list & Explain:________________________________________________________
Is the child allergic to LATEX? O Yes O No Any other allergies? O Yes O No If Yes, please list: ___________________________________
Has the child been treated for any of the following? O ADHD/ADD O Autism
O Arthritis O Asthma O Blood Disorder O Cancer
O Diabetes O Epilepsy/Seizures O Heart Condition O HIV/AIDS
O Liver problems/Hepatitis O Mitral Valve Prolapse O Nervous Disorder O Tuberculosis
Please describe any current medical treatment including any medications not mentioned above:__________________________________________
Race (optional) O African American O American Indian O Asian O Caucasian O Chinese O Japanese O Korean O Latin O South Pacific
I understand that the information that I have provided 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.
SIGNATURE
Relationship __________________________________________________________________________ Date _____________________________
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Np Boy Hh Info Form

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Completed 9 February 2022

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