New Patient - Child Form"*" indicates required fieldsPatient'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 needsWhom may we thank for referring you to our office?Medical HistoryPhysician's NameAddressPhoneHas your child experienced any health problems?* Yes NoIf yes, explainAny major change in your child's health recently?* Yes NoIf yes, explainIs your child currently under a physician's care?* Yes NoIf yes, explainIs your child currently taking and medications?* Yes NoIf yes, list themIs your child currently allergic to any medications?* Yes NoIf yes, list themHave your child received a blood transfusion?* Yes NoIf yes, explainHave your child's tonsils or adenoids been removed?* Yes NoIf yes, when?ADD/Behavior Issues* Yes NoIf yes, explainHas 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 NoneIs there any other conditions or problems that you think we should know about?*Growth Information for Patients UNDER 16 Years of AgeBecause 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 NoGirls - Has she started menstruations? Yes NoBoys - Has his voice changed? Yes NoHeight*Do you feel growth is completed?* Yes NoFather's Height*Mother's Height*Adopted?* Yes NoNumber of SiblingsDental HistoryDentist's NameAddressPhoneFrequency of dental checksDate of last visit?Is there any unfinished care to be completed with child's dentist?* Yes NoIf yes, explainIs your child frightened about dental treatment?* Yes NoIf yes, explainHas your child has an unpleasant experience at a dental office?* Yes NoIf yes, explainHas your child has and face dental injuries?* Yes NoIf yes, explainIs there a history of thumb sucking?* Yes NoIf yes, when did it stop?Does your child play and instrument?* Yes NoIf yes, which instrument?Has your child consulted and orthodontist previously?* Yes NoIf yes, with whom?Have teeth (either primary or permanent) been removed?* Yes NoHas your child had any previous otherdontic treatment?* Yes NoIf yes, with whom?Are you satisfied with prior treatment?* Yes NoExplain*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 - SleepingPediatric Sleep QuestionnairePatients under 18 years of agePatient NameDatePlease answer on behalf of your child for the past monthWhile sleeping, does your child...Snore more than half the time?* Yes No UnsureAlways Snore?* Yes No UnsureSnore Loudly?* Yes No UnsureHave trouble breathing, or struggle to breathe?* Yes No UnsureHave "heavy" or loud breathing?* Yes No UnsureHave you ever seen your child stop breathing during the night?* Yes No UnsureDoes your child...Tend to breathe through the mouth during the day?* Yes No UnsureHave a dry mouth on making up in the morning?* Yes No UnsureWake up feeling unrefreshed in the morning?* Yes No UnsureHave a problem with sleepiness during the day?* Yes No UnsureHas a teacher commented that your child appears sleepy during the day?* Yes No UnsureDid your child stop growing at a normal rate at any time since birth?* Yes No UnsureIs your child overweight?* Yes No UnsureMy child often...Does not seem to listen when spoken to directly?* Yes No UnsureHas difficulty organizing tasks and activities?* Yes No UnsureIs easily distracted by extraneous stimuli?* Yes No UnsureFidgets with hands, feed, and/or squirms in seat?* Yes No UnsureIs 'on the go' or often acts as if 'driven by a motor'?* Yes No UnsureInterrupts or intrudes on others?* Yes No Unsure
