Child Patient Form in Lynnwood, WA | Balance Epigenetic Orthodontics

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Patient's Name*

Birthdate*

Gender*

Age*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Parent / Legal Guardian*

Relationship*

Home Phone / Cell*

Email Address*

Please explain your reason for seeking treatment so that we may best meet your needs*

Please explain your reason for seeking treatment so that we may best meet your needs

Whom may we thank for referring you to our office?

Medical History

Physician's Name

Address

Phone

Has your child experienced any health problems?*

Yes

If yes, explain

Any major change in your child's health recently?*

Yes

If yes, explain

Is your child currently under a physician's care?*

Yes

If yes, explain

Is your child currently taking and medications?*

Yes

If yes, list them

Is your child currently allergic to any medications?*

Yes

If yes, list them

Have your child received a blood transfusion?*

Yes

If yes, explain

Have your child's tonsils or adenoids been removed?*

Yes

If yes, when?

ADD/Behavior Issues*

Yes

If yes, explain

Has your child experienced any of the following conditions?

Has your child experienced any of the following conditions?*

Heart Murmur

Heart Surgery

Rheumatic Fever

Endocrine Disorders

Prolonged Bleeding

Anemia

Blood Disease

Development Disorder

Hives / Rash

Hepatitis

Diabetes

Kidney Disease

Liver Disease

Tuberculosis

Asthma

Bronchitis

Epilepsy

Emotional Problems

Frequent Headaches

Nervous / Anxious

Cancer

Bone Disorders

Growth Disorders

Mouth Breather

Herpes (Fever Blisters)

Tonsilitis

None

Is there any other conditions or problems that you think we should know about?*

Growth Information for Patients UNDER 16 Years of Age

Because growth can be an important factor in orthodontic treatment planning, your answers to the following questions are needed to aid our selection of treatment alternatives:

Has your child reached puberty?*

Yes

Girls - Has she started menstruations?

Yes

Boys - Has his voice changed?

Yes

Height*

Do you feel growth is completed?*

Yes

Father's Height*

Mother's Height*

Adopted?*

Yes

Number of Siblings

Dental History

Dentist's Name

Address

Phone

Frequency of dental checks

Date of last visit?

Is there any unfinished care to be completed with child's dentist?*

Yes

If yes, explain

Is your child frightened about dental treatment?*

Yes

If yes, explain

Has your child has an unpleasant experience at a dental office?*

Yes

If yes, explain

Has your child has and face dental injuries?*

Yes

If yes, explain

Is there a history of thumb sucking?*

Yes

If yes, when did it stop?

Does your child play and instrument?*

Yes

If yes, which instrument?

Has your child consulted and orthodontist previously?*

Yes

If yes, with whom?

Have teeth (either primary or permanent) been removed?*

Yes

Has your child had any previous otherdontic treatment?*

Yes

If yes, with whom?

Are you satisfied with prior treatment?*

Yes

Explain*

Does your child have a history of any of the following?

Does your child have a history of any of the following?*

Clenching Teeth

Grinding Teeth

Bed Wetting

Muscular Soreness Around Neck

Jaw Joint Soreness

Headaches

Snores at Night

Ringing In Ears

Jaw Joint Popping/Clicking

Speed Problems?

Mouth Breathing - Awake

Mouth Breathing - Sleeping

Pediatric Sleep Questionnaire

Patients under 18 years of age

Patient Name

Date

Please answer on behalf of your child for the past month

While sleeping, does your child...

Snore more than half the time?*

Yes

Unsure

Always Snore?*

Yes

Unsure

Snore Loudly?*

Yes

Unsure

Have trouble breathing, or struggle to breathe?*

Yes

Unsure

Have "heavy" or loud breathing?*

Yes

Unsure

Have you ever seen your child stop breathing during the night?*

Yes

Unsure

Does your child...

Tend to breathe through the mouth during the day?*

Yes

Unsure

Have a dry mouth on making up in the morning?*

Yes

Unsure

Wake up feeling unrefreshed in the morning?*

Yes

Unsure

Have a problem with sleepiness during the day?*

Yes

Unsure

Has a teacher commented that your child appears sleepy during the day?*

Yes

Unsure

Did your child stop growing at a normal rate at any time since birth?*

Yes

Unsure

Is your child overweight?*

Yes

Unsure

My child often...

Does not seem to listen when spoken to directly?*

Yes

Unsure

Has difficulty organizing tasks and activities?*

Yes

Unsure

Is easily distracted by extraneous stimuli?*

Yes

Unsure

Fidgets with hands, feed, and/or squirms in seat?*

Yes

Unsure

Is 'on the go' or often acts as if 'driven by a motor'?*

Yes

Unsure

Interrupts or intrudes on others?*

Yes

Unsure

Child Patient Form

New Patient - Child Form

Medical History

Has your child experienced any of the following conditions?

Growth Information for Patients UNDER 16 Years of Age

Dental History

Does your child have a history of any of the following?

Pediatric Sleep Questionnaire

While sleeping, does your child...

Does your child...

My child often...

Ready to Prioritize Your Wellbeing?