Child Patient Form

Child Patient Information














Responsible Party Information




Residence




Mailing Address




Previous Address ( If less than 3 years )















Spouse Information









Dental Insurance

(Please bring a copy of your Dental Insurance Card. This may be different than your medical carrier. Please verify.)

















Emergency Information




Medical History





Are you taking any medication?
YesNo
Are you allergic to any medication?
YesNo
Do you have a history of a major illness?
YesNo
Have you had any operations?
YesNo
Have you ever been involved in a serious accident?
YesNo
Have you ever smoked or chewed tobacco?
YesNo
Have seen a physician in the last 12 months? Why?
YesNo
Are you pregnant?
YesNo
Has menstruation started?
YesNo

Check any of the medical conditions below that you have had or currently have.

Abnormal Bleeding
YesNo
Anemia
YesNo
Arthritis
YesNo
Asthma or Hayfever
YesNo
Bone Disorders
YesNo
Congenital Heart Defect
YesNo
Diabetes
YesNo
Dizziness
YesNo
Epilepsy
YesNo
Gastrointestinal Disorders
YesNo
Heart Problems
YesNo
Heart Murmur
YesNo
Hepatitis/Liver problems
YesNo
Herpes
YesNo
High Blood Pressure
YesNo
HIV / Aids
YesNo
Kidney problems
YesNo
Nervous Disorders
YesNo
Pneumonia
YesNo
Prolonged Bleeding
YesNo
Radiation/Chemotherapy
YesNo
Rheumatic Fever
YesNo
Tuberculosis
YesNo
Tumor or Cancer
YesNo

Dental History




Are you presently in any dental pain?
YesNo
Have you ever experienced any unfavorable reaction to dentistry?
YesNo
Have your wisdom teeth been removed?
YesNo
Have you ever lost or chipped any teeth?
YesNo
Have there been any injuries to face, mouth, or teeth?
YesNo
Is any part of your mouth sensitive to temperature? Where?
YesNo
Is any part of your mouth sensitive to pressure? Where?
YesNo
Do your gums bleed when you brush?
YesNo
Do you have any type of thumb or tongue habit?
YesNo
Are you a mouth breather?
YesNo
Have you ever seen an orthodontist? If yes, who and when?
YesNo
Do you have a positive attitude toward receiving orthodontic treatment?
YesNo
Has anyone in your family received orthodontic treatment?
YesNo
Does your mouth feel uncomfortable when you awake in the morning?
YesNo
Are you aware of your jaw clicking or popping?
YesNo
Are you aware of clenching your teeth during the day?
YesNo
Have you ever been told that you grind your teeth?
YesNo
Do you have “tension” headaches?
YesNo
Have you ever experienced chronic ringing in your ears?
YesNo
Are you adopted?
YesNo
Are you aware that some appointments will be during school hours?
YesNo



Contact Us Today!

Do not wait, contact us today for free and find out more

Chicago Office Location

7070 N. Western Ave
Chicago, IL 60645

(773) 508-5588
Northbrook Office Location

1500 Shermer Rd. #100
Northbrook, IL 60062

(847) 562-8858
Glencoe Office Location

650 Vernon Ave
Glencoe, IL 60022

(847) 835-3200