Updated RECORDS Child Info Form

Updated RECORDS Child Patient Information Form

* Name: (Required)

Nickname

Sex: Female Male

Age

Birthdate

Street Address

City

State

Zip Code

* Email: (Required)

Phone

Name & Age of Siblings

If the patient is a college student, please provide a residence address:

Whom may we thank you referring you to our office?

PARENT'S/GUARDIAN'S INFORMATION

Father's/Guardian's Name

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Mother's/Guardian's Name

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

* Email Address: (Required)

RESPONSIBLE PARTY INFORMATION

Person responsible for account

Billing address

City

State

Zip Code

Relationship to patient

EMERGENCY CONTACT

Name

Relationship

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

The office of Dr. Brady will be happy to process your orthodontic claims.

To successfully process your claims, all of the following information is necessary.

If you do not have all of the required information we suggest you contact your Human Resources Representative and they can help you with any missing information.

DENTAL INSURANCE INFORMATION

Primary Insured's Name

Insured's Date of Birth

Insured's SSN

Insurance ID#

Insured's Phone Number

Insurance Company

Insurance Co. Full Address

Insured's Employer

Group No.

DUAL INSURANCE INFORMATION (if applicable)

Secondary Insured's Name

Insured's Date of Birth

Insured's SSN

Insured's ID#

Insured's Phone Number

Insurance Company

Insurance Co. Full Address

Insured's Employer

Group No.

MEDICAL HISTORY

Physician

Phone

Physician's Address

City

State

Zip Code

General Health and Known Illnesses

Present Medications

Surgeries (with approximate dates)

Is there a possibility that the patient may be pregnant? Yes No

Has the patient ever had an allergic reaction to medication? Yes No

If Yes, please list the medication(s)

Has the patient ever had an allergic reaction to foods; latex; any metals, especially Nickel or Titanium, or any other substance? Yes No

If Yes, please list your allergy(ies) to any of the above mentioned

Has the paitent ever had any of the following:

Bleeding History: Yes No

Cancer: Yes No

Diabetes: Yes No

Hearing Loss: Yes No

Epilepsy: Yes No

Liver Problems: Yes No

High Blood Pressure: Yes No

Migraine Headaches: Yes No

Stomach Ulcers: Yes No

Hepatitis: Yes No

Kidney Problems: Yes No

AIDS or other immune system disorder: Yes No

Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion arteriosclerosis, stroke): Yes No

Damaged heart valves (Mitral valve prolapse, artificial heart valve, heart murmur) or any other conditions which may require you to be premedicated: Yes No

If yes to any of the above, does your condition require you to be premedicated?

DENTAL HISTORY

Patient's Dentist

Date of Last Visit (approx.)

Dentist's Address

City

State

Zip Code

Have you previously consulted an orthodontist? Yes No

If yes, when and with whom?

Have you consulted any other dental specialty? Yes No

If yes, when and with whom?

Is there a history of congenitally missing teeth? Yes No

Patient Relative(s)

Do your gums bleed when you brush your teeth? Yes No

Is any part of your mouth sensitive to temperature? Yes No

Is any part of your mouth sensitive to pressure? Yes No

Have you ever sucked your thumb or finger(s)? Yes No

If so, have you stopped this habit? Yes No

Do you breathe predominantly through your mouth? Yes No

Have you had your tonsils/adenoids removed? Yes No

If Yes, when?

Do you clench or grind your teeth during the day? Yes No

Have you been made aware of clenching or grinding your teeth during the night? Yes No

Do you now have, or have you ever had, pain in your jaw joint or the sides of your face (in and about the ears)? Yes No

Have you ever had clicking or popping in your jaw joint? Yes No

If Yes, please explain.

Have you ever experienced pain when opening wide? Yes No

Have you had injury to your jaw? Yes No

If Yes, please explain.

Have you had any injury to your teeth? Yes No

If Yes, please explain.

If you would like us to get to know your child better, please have them fill out this section of the form.

Welcome to Dr. Brady's orthodontic office! We're looking forward to meeting you. Help us get to know you better by answering the following:

My nickname is

I go to school at

I am

years old and I'm in the grade.

Some of my hobbies/interests include:

My favorite food is

My favorite type of music or group is

I love to:

My friends that come here are

I think having braces would be

If you have any pets, what are they?

Is there anything special you would like us to know about you?