Child Health History Form

Orthodontic Health History

Date:

First

Last

Birth Date:

Age:

Sex:

Male

Female

Patient’s Address:

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

School:

Grade:

Hobbies/sports:

Mother's Name

Father's Name

Father’s E-Mail Address:

Mother’s E-Mail Address:

Mother’s cell #:

Father’s cell #:

Sibilings:

Parental Marital status:

Who has legal custody of patient?

Date of last exam:

First

Middle

Last

First

Middle

Last

INSURANCE INFORMATION

Person financially responsible for this account:

Last

Insurance coverage for Orthodontic treatment?

Insurance Company:

Address:

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Primary Policy Holder Name:

Birth Date:

ID#

Group #

Insurance Company:

Address:

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Primary Policy Holder Name:

Birth Date:

ID#

Group #

PATIENT PROFILE

Is the patient concerned with the appearance of their smile?

Why do you think orthodontic treatment is needed?

Has there been any prior orthodontic treatment or appliances?

Is there any information that would help us better treat the patient?

HEALTH HISTORY

Has your child ever had a health problem?

YES

Please explain:

Has your child ever been hospitalized?

YES

Is your child allergic to anything?

YES

Has your child started her menstrual cycle? (If applicable)

YES

DENTAL HISTORY

Have there been any accidents or trauma to the teeth or face?

Are there any teeth missing?

Have any teeth been removed?

Are there any other dental conditions or problems that we should be aware of?

I request and authorize Dr. Watson to examine, clean and provide dental treatment on my child’s teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Watson to diagnose and/or treat my child’s dental problem. I will allow photographs to be taken of my child or child’s teeth for diagnostic purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Signature__________________________________________ Relationship to patient___________________ Date_____________

20 YEARS creating timeless smiles!

INSURANCE INFORMATION

PATIENT PROFILE

HEALTH HISTORY

DENTAL HISTORY

Jeremy R. Watson DDS, MS 1248 East 90 North, Suite 201, American Fork, UT 84003