Child Health History

Last Name:

First Name:

MI:

Nickname:

Today's Date:

Birthdate:

Age:

Male Female

School:

Grade:

Hobbies / Sports:

Child's Home #:

Child's Home Address:

Street, APT/CONDO#, City, State, Zip

Who is Accompanying Your Child Today?

Name:

Relation:

Do you have legal custody of this child?

Yes No

Whom may we Thank for referring you?

Please list brothers / sisters with age

Add Another Sibling

General Dentist:

Date:

Parent's Marital Status:

Single Married Partnered Separated Divorced Widowed

Mother's Information

Step Mother Guardian

Name:

Birthdate:

Work Phone:

Ext:

Home Phone:

Cell Phone:

Employer:

How long there?

Job Title:

Email address:

SS#:

Father's Information

Step Father Guardian

Name:

Birthdate:

Work Phone:

Ext:

Home Phone:

Cell Phone:

Employer:

How long there?

Job Title:

Email address:

SS#:

Person Responsible for Account

Name:

Relation:

Billing Address:

Previous Address:

Home Phone:

Cell Phone:

Employer:

Work Phone:

Ext:

SS#:

Email address:

Primary Orthodontic Insurance

Orthodontic Coverage:

Yes No

Insurance CO. Name:

Insurance CO. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #)

Policy Owner's Name:

Relationship to Patient:

Birthdate:

ID #:

Policy Owner's Employer:

Employer's Address:

Secondary Orthodontic Insurance

Orthodontic Coverage:

Yes No

Insurance CO. Name:

Insurance CO. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #)

Policy Owner's Name:

Relationship to Patient:

Birthdate:

ID #:

Policy Owner's Employer:

Employer's Address:

In the event of an emergency, is there someone who lives near you that we could contact?

His/Her Name:

Relation:

Work Phone:

Home Phone:

What are the main concerns that you would like orthodontics to accomplish?

Has your child ever been evaluated or had orthodontic treatment before?

Yes No

Have there been any injuries to the face, mouth, teeth, or chin?

Yes No

List any musical instruments played:

Have adenoids or tonsils been removed?

Yes No

Has your child been informed of any missing or extra permanent teeth?

Yes No

Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)?

Yes No

Does your child brush his / her teeth daily?

Yes No

Floss his / her teeth daily?

Yes No

Is your child currently under the care of a physician?

Yes No

Child's Physician?

Phone #:

Date of Last Visit:

Has puberty begun?

Yes No

Has menstruation begun?

Yes No

(GIRLS) If so, what date?

Please describe your child's current health:

Good Fair Poor

Please list all drugs that your child is currently taking:

Add another drug

Has your child taken or presently taking medication for ADD / ADHD?

Yes No

Please list all drugs / things your child is allergic to:

Add another allergy

Is your child allergic to:

Latex Metals/Nickel Plastics

Has your child ever had any of the following medical problems?

Please discuss any medical problems that your child has had:

Does you child require antibiotics before any dental care?

Yes No

Has your child ever experienced any of the following?

Neighbor or Relative not living with you.

Name:

Phone #:

Address:

The Parent or Guardian who accompanies the child is responsible for payment.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform any necessary dental services my child may need.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent or Guardian:

Date:

Acknowledgement of Receipt of Notice of Privacy Practices

*You may refuse to sign this acknowledgement*

Please VIEW-READ-PRINT our Notice of Privacy Practices by clicking HERE

⠀ ⠀ ⠀ ⠀ ⠀ ⠀ ⠀ ⠀ ⠀I,

have received a copy of Wermerson Orthodontics Notice of Privacy Practices.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

(Patient/Parent/Guardian signature)

Date:

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the patient named herein

Initials:

Date:

Doctors Comments:

For Wermerson Orthodontics office use, in the event, the Notice of Privacy Practices isn’t signed. We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practice, but acknowledgment could not be obtained because:

Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining the acknowledgement Other (Please specify)

If Other, explain

Your information will be encrypted.