Child Medical History | Scantlebury Orthodontics

Patient/Child Information

First Name

First

Last Name

Last

Gender

Dentist's Full Name

Email

Referred By

Birth Date

Any other siblings seen by us

Age

How did you hear about us?

Invisalign Website
Google/Internet

Home Address

Street Address

Other

Parent Information

Parent 1

First Name

First

Last Name

Last

Social Security #

Birthday

Home Address

Street Address

Home Phone #

Cell Phone #

Work Phone #

Relationship to Patient

Parent 2

First Name

First

Last Name

Last

Social Security #

Birthday

Home Address

Street Address

Home Phone #

Cell Phone #

Work Phone #

Relationship to Patient

Patient's Medical History

Is patient in good health?

Yes
No

Any major illness?

Yes
No

Does patient have tendency to:

Colds

Yes
No

Sore Throats

Yes
No

Ear Infections

Yes
No

Has patient been under the care of a physician for any illness in the last 12 months?

Yes
No

Please select “Yes” to any illness or disability for which the patient is undergoing treatment:

Diabetes

Yes
No

Anemia

Yes
No

Epilepsy

Yes
No

Nervous Disorders

Yes
No

Asthma

Yes
No

Endocrine Problems

Yes
No

Tuberculosis

Yes
No

Heart Trouble

Yes
No

Prolonged Bleeding

Yes
No

Rheumatic Fever

Yes
No

Fainting/Dizziness

Yes
No

Bone Disorders

Yes
No

Any other illness we should be aware of

Have tonsils and adenoids been removed?

Yes
No

At What Age?

List any drugs/medications now being taken, and give reason

List any allergies or drug sensitivities

Has the patient reached puberty?

Yes
No

Height

Weight

Any instruments played?

Is the patient involved in any other activities?

Patient's Dental History

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

Yes
No

Has the patient ever sucked a thumb or finger?

Yes
No

Until what age?

Does the patient have any speech problems?

Yes
No

Is the patient a mouth breather?

Yes
No

When does patient mouth breath?

While awake
While asleep

Have you been informed of any missing permanent teeth?

Yes
No

Has either parent ever had orthodontic treatment?

Yes
No

Have you previously consulted an orthodontist?

Yes
No

Reason for consultation today?