Align Orthodontics > About Us > Child Patient Form Please check the required fields Patient's First Name: Patient's Last Name: Prefers to be called: Please list all persons who have financial or custodial responsibility for the patient and provide their relationship to the patient and contact information if different from patient's contact information: DENTAL (Mark All That Apply: Check box for YES, Leave blank for NO) Has your child ever experienced an unfavorable reaction to dentistry? Have you been informed that your child has of extra or missing teeth? Is any part of your child's mouth sensitive to temperature/pressure? Does your child brush his/her teeth daily? Does your child floss regularly? Does your child have any kind of finger, thumb/tongue habit? Has your child ever had any pain, tenderness, clicking, or popping in his/her jaw (TMJ/TMD)? Does your child clench/grind his/her teeth? Does your child have any difficulty chewing/swallowing food? Does your child's bite feel uncomfortable? Indicate your child's feelings/attitude towards having orthodontic treatment: Wants treatment Unwilling but agrees Understands treatment is necessary Uncooperative Has an orthodontist been previously consulted? Are you aware of any dental work that needs to be completed prior to orthodontic treatment? Date of your child's most recent dental examination: -MM- 01 02 03 04 05 06 07 08 09 10 11 12 / -DD- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / -YYYY- 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 Other dentists/dental specialist that are being seen and reason: Have there been any injuries to your child's face, mouth, teeth or chin? If yes, please explain: Have any teeth been removed by extraction? If yes, please explain: Has anyone else in your family received orthodontic treatment? If yes, how did they feel about the results? MEDICAL - Has your child ever had any of the following diseases or medical conditions? (Check all that apply) Abnormal Bleeding/Hemophilia Anemia Arthritis Asthma/Hayfever Blood Disorders Bone Disorders Congenital Heart Defect Depression/Mental Illness Diabetes Dizziness Endocrine Problems Epilepsy Gastrointestinal Disorders Heart Problems Heart Murmur Hepatitis/Liver Problems Herpes High Blood Pressure HIV+/AIDS Kidney Problems Nervous Disorders Pneumonia Prolonged Bleeding Radiation/Chemotherapy Rheumatic Fever Tuberculosis Tumor/Cancer Does your child have any other medical condition not described above? If yes, please explain: Has your child had an allergic reaction to any of the following? (Check all that apply) Aspirin Codeine Dental Anesthetics Erythromycin Latex Penicillin Tetracycline Metals Others Please list any other medications to which your child has had an allergic reaction: Has your child ever had to take antibiotics prior to a dental visit/checkup? Has your child been diagnosed with any emotional disorders, including ADD/ADHD? If yes, pelase list any medications: Please list all other medications that your child is currently taking: Is your child currently under the care of a physician? If yes, please explain: Please explain any medical problems that your child has had in the past: I have read and I understand the above questions. I will not hold Dr. Henry or any member of his staff responsible for any errors or omissions that have been made in the completion of this form. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any later changes to the history record or medical/dental status. We will discuss your child's treatment with parents/legal guardians/person(s) financially responsible for his/her treatment and referring doctors/dentists for the furtherment of his/her treatment. Signature of parent/legal guardian Date 10 01 02 03 04 05 06 07 08 09 11 12 / 05 01 02 03 04 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2024 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 Security Code: * Reload Image :: PHP FormMail Generator ::