Patient Information (for minors)
Patient's Name
*
Home Address
*
City
*
Postal Code
*
DOB
*
Present Age
*
Gender
*
Male
Female
Do you have any children or relatives who have had treatment in this practice?
*
Yes
No
How were you referred to our practice?
*
School
*
Grade
*
Physician
*
Dentist
*
Patient's Parental Information
Parent 1 Name
*
Email Address
*
Phone Number
*
Cell Number
*
Business Phone
*
Address (if different then above)
*
Marital Status
*
Employers Name
*
Parent 2 Name
*
Email Address
*
Phone Number
*
Cell Number
*
Business Phone
*
Address (if different then above)
*
Marital Status
*
Employers Name
*
Insurance
Do you have dental insurance that covers orthodontic treatment?
*
Yes
No
If yes, please provide more details below. If no, please enter N/A in the fields below.
Primary Subscriber Name
*
Primary Subscriber Birthdate
*
Primary Insurance Carrier
*
Primary Group Number
*
Primary ID Number
*
Primary Reimburses at %
*
Primary Maximum
*
Secondary Subscriber Name
*
Secondary Subscriber Birthdate
*
Secondary Insurance Carrier
*
Secondary Group Number
*
Secondary ID Number
*
Secondary Reimburses at %
*
Secondary Maximum
*
Patient History
Is patient in perfect health?
*
Yes
No
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
Is patient currently taking any medication?
*
Yes
No
Is patient in a high risk group for HIV Infection?
*
Yes
No
Allergies
*
Yes
No
Does patient have a history of any other serious illness?
*
Yes
No
Any injuries to the head?
*
Yes
No
Have you been informed of any missing or extra teeth?
*
Yes
No
Does the patient have a history of any of the following?
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
Finger sucking
*
Yes
No
Lip biting or sucking
*
Yes
No
Has the patient ever received treatment for any of the above problems?
*
Yes
No
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
