Patient Information (for minors) (Must be completed by parental guardian) Patients Name * Home Address * City * Postal Code * DOB * Present Age * Gender * M F Do you have any siblings or relatives who have had treatment in this practice? * Yes No What is their name(s)? What is their age(s)? How were you referred to our practice? * School * Grade Physician Dentist * Patients Parental Information Salutation Mr.Dr. Fathers Name Marital Status * Address (if different then above) Phone Number Cell Number Email Address Employers Name Business Phone Dropdown Miss.Ms.Mrs.Dr. Mothers Name Marital Status * Address (if different then above) Phone Number Cell Number Email Address Employers Name Business Phone Insurance Do you have dental insurance that covers orthodontic treatment? * Yes No Primary * Primary Subscriber Name * Primary Subscriber Birthdate * Primary Insurance Carrier * Primary Group Number * Primary ID Number * Primary Reimburses at % * Primary Maximum * Secondary (Please Add NA if Not Applicable) * Secondary Subscriber Name (Please Add NA if Not Applicable) * Secondary Subscriber Birthdate (Please Add NA if Not Applicable) * Secondary Insurance Carrier (Please Add NA if Not Applicable) * Secondary Group Number (Please Add NA if Not Applicable) * Secondary ID Number (Please Add NA if Not Applicable) * Secondary Reimburses at % (Please Add NA if Not Applicable) * Secondary Maximum (Please Add NA if Not Applicable) * Patient Information Patient's Height * Father's Height Mothers Height Has she started menstration? Yes No When Has his voice changed? Yes No When Is patient in perfect health? * Yes No if no please specify * Has an Orthodontist been previously consulted? * Yes No Has the patient had any orthodontic treatment? * Yes No Is patient under the care of a physician for any reason? * Yes No If yes, please give a reason * Is patient currently taking any medication? * Yes No If yes, please list * Is patient in a high risk group for HIV Infection? * Yes No Allergies * Yes No If yes, please specify * Does patient have a history of any other serious illness? * Yes No If yes, please specify * Any injuries to the head? * Yes No If yes, please specify * Have you been informed of any missing or extra teeth? * Yes No Has patient any history of? Autism * Yes No Down Syndrome * Yes No Diabetes * Yes No Epilepsy * Yes No Heart Trouble * Yes No Gland or Endocrine Problems * Yes No Rheumatic Fever * Yes No Fainting or Dizziness * Yes No Bone Disorders * Yes No Nervous Disorders * Yes No Congenital Abnormalities * Yes No Emotional Disorders * Yes No Tuberculosis * Yes No Liver Problems * Yes No Blood Disorders * Yes No Hepatitis * Yes No Anemia * Yes No HIV Infection * Yes No Prolonged Bleeding * Yes No Kidney Problems * Yes No Frequent Colds * Yes No Asthma * Yes No Ear Infections * Yes No Chronic Nasal Obstruction * Yes No Mouthbreathing * Yes No Adenoid Problems * Yes No Have Adenoids been removed? * Yes No Tonsillitis * Yes No Have Tonsils been removed? * Yes No Tongue thrusting * Yes No Tooth grinding or clenching * Yes No Headaches (frequent) * Yes No Muscular soreness around head and neck * Yes No Jaw joint clicking of popping * Yes No Thumbsucking * Yes No Until what age Finger sucking * Yes No Until what age Lip biting or sucking * Yes No Until what age Has the patient ever received treatment for any of the above problems? * Yes No If yes, please specify Does the patient have regular dental checkups? * Yes No Date of last checkup Toothbrushing * After every meal Once per day Twice per day Does the patient floss? * Yes No Does the patient want treatment? * Yes No Indifferent Reason for seeking orthodontic consultation? In accordance with Canada's federal anti-spam regulations, I accept to be contacted through email be South Surrey Smiles Yes No I hereby acknowledge that the health history I have provided is correct. Yes my information is correct Captcha If you are human, leave this field blank. Δ
