Private Medical Dental History Form (Under 18)A thorough medial history is essential to a complete orthodontic evaluation.This form will take less than 10 minutes to complete. Your answers are for office records only, and are confidential.PatientTitle:* MrMrsMsMissDrOtherFirst name:*Last name:*I prefer to be called:Date of birth:* (dd/mm/yyyy)Sex:* MaleFemaleEthnicity:Hobbies/activities:School:Grade:Home address:*Postcode:*Email:*Home phone:*Mobile phone:Parent/GuardianPatient lives with (check all that apply):* MotherFatherStepmotherStepfatherGrandparent(s)OtherParent's title:* MrMrsMsMissDrOtherParent's full name:*Home address: (if different)Home phone: (if different)Mobile phone:Work phone:DentistDentist name:*Dentist address:*General InformationHow often does your child brush?*How often does your child floss?What concerns you about your child's teeth?Do you think that any of your child's activities affect his/her face, teeth or jaws?If so, how:Have you noticed any unusual changes in your child's face or jaws?How does your child feel about orthodontic treatment?Who suggested that your child might need orthodontic treatment?*Why did you select our office?*Describe any previous orthodontic treatment or consultations:Have any other family members been treated in this office?Please name them:Are you considering private orthodontic treatment?* YesNoCan you think of any friend you would like us to contact regarding possible treatment?The British Orthodontic Society recommends a child be assessed from the age of 7 and onwards.Do you have any siblings you would like to register with us? click hereName: (1st sibling)Date of birth: (dd/mm/yyyy)Name: (2nd sibling)Date of birth: (dd/mm/yyyy)Name: (3rd sibling)Date of birth: (dd/mm/yyyy)Financial ResponsibilityWho is financially responsible for this account?*Medical HistoryFor the following questions set yes, no, or don't know.Now or in the past, has your child had:Any injuries to face, head, neck?YesNoDont KnowEndocrine or thyroid problems?YesNoDont KnowDiabetes or low sugar?YesNoDont KnowAIDS or HIV positive?YesNoDont KnowHepatitis, jaundice or other liver problems?YesNoDont KnowSeizures, fainting spells, neurologic problem?YesNoDont KnowMental health disturbance or depression?YesNoDont KnowHistory of eating disorder (anorexia, bulimia)?YesNoDont KnowFrequent headaches or migraines?YesNoDont KnowHigh or low blood pressure?YesNoDont KnowExcessive bleeding or bruising tendency, anaemia?YesNoDont KnowChest pain, shortness of breath, tire easily, swollen ankles?YesNoDont KnowHeart defects, heart murmur, rheumatic heart disease?YesNoDont KnowSkin disorder (other than common acne)?YesNoDont KnowVision, hearing, or speech problems?YesNoDont KnowFrequent ear infections, colds, throat infections?YesNoDont KnowAsthma, sinus problems, hay fever?YesNoDont KnowTonsil or adenoid condition?YesNoDont KnowDoes your child frequently breathe through his/her mouth? YesNoDont KnowHas your child had allergies or reactions to any of the following?Local anesthetics:YesNoDont KnowLatex (gloves, balloons):YesNoDont KnowIbuprofen, Aspirin:YesNoDont KnowPenicillin:YesNoDont KnowOther substances:YesNoDont KnowMetals (jewelry, clothing snaps):YesNoDont KnowAcrylics:YesNoDont KnowPlant pollens:YesNoDont KnowAnimals:YesNoDont KnowFoods:YesNoDont KnowDental HistoryNow or in the past, has your child had:Erupting teeth very early or very late?YesNoDont KnowPrimary (baby) teeth removed that were not loose?YesNoDont KnowPermanent or extra (supernumerary) teeth removed?YesNoDont KnowSupernumerary (extra) or congenitally missing teeth?YesNoDont KnowChipped or injured primary or permanent teeth?YesNoDont KnowAny sensitive or sore teeth?YesNoDont KnowAny lost or broken fillings?YesNoDont KnowJaw fractures, cysts, infections?YesNoDont KnowAny teeth treated with root canals or pulpotomies?YesNoDont KnowFrequent ulcers or cold sores?YesNoDont KnowHistory of speech problems or speech therapy?YesNoDont KnowDifficulty breathing through nose?YesNoDont KnowMouth breathing habit or snoring at night?YesNoDont KnowHistory of speech problems?YesNoDont KnowFrequent oral habits (sucking finger, chewing pen, etc.)?YesNoDont KnowTeeth causing irritation to lip, cheek or gums?YesNoDont KnowTooth grinding or clenching?YesNoDont KnowClicking, locking in jaw joints?YesNoDont KnowSoreness in jaw muscles or face muscles?YesNoDont KnowHas your child been treated for "TMJ" or "TMD" problems?YesNoDont KnowAny serious trouble associated with previous dental treatment?YesNoDont KnowHas your child ever been diagnosed with gum disease or pyorrhea?YesNoDont KnowWaiverI have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health. Parent/guardian accepts these terms*Date:* (dd/mm/yyyy)* Required fieldsPlease leave this field empty.