Child Patient And Responsible Party Information Form (Page 3 of 3) in pdf

Yes



Does the patient gag easily?



Do any of your teeth hurt? If yes, upper right  upper left  lower left  lower left 



Have any wisdom teeth been removed? How many?



Have you ever had treatment for a periodontal disease (gum disease)? If yes, when



Have you ever had any previous orthodontic treatment (braces)? If yes, when

If yes, doctor’s name and address



Have there been any injuries to your mouth or teeth? If yes, describe



Have you ever been any injury in the head and neck area? If yes, describe



Have you ever fallen and bumped your chin, or received a blow to your jaws? If yes,

describe



Have you ever had any surgery in the head and neck area? If yes, describe



Do you clench or grind your teeth? If yes, while sleeping r under stress r other_______



Do your jaw muscles ever feel tired? If yes, when



Do you ever notice soreness, tightness or pain in the muscles around the jaws and face? If

yes, describe



Does it hurt to chew? If yes, where does it hurt?



Do you hear clicking (popping) or grating sounds in your jaw joints? If yes, please

describe

Right

Left

Since when

During what activity

 Clicking:



 Grating:



Did these joints begin gradually or suddenly: gradually  suddenly 



Was there some specific event that started the joints sounds? If yes, describe



Have you ever experienced difficulty in opening or closing your jaws? If yes, describe



Have your jaws ever “locked” closed? If yes, describe



Have your jaws ever “locked” wide open? If yes, describe



Do you have pain in your jaws joints? If yes, right  left 

since when?

Did your pain start gradually or suddenly?  Gradually  suddenly

During what activity?

Describe nature of pain

What increases the pain

What decreases the pain?

Do you have any of the following habits?

Yes



Finger/Thumb sucking



Nail or Lip Biting



Tongue thrust habit



Gum Chewing



Ice Chewing

Doctors Notes:__________________________________________________________________________

______________________________________________________________________________________

I, the undersigned, certify that I have read and understand the above medical and dental information, have

reviewed it, and find it accurate. If there are any changes to the patient’s clinical history, I recognize that it is

my responsibility to inform this office. I also authorize Dr. Maro, and staff to perform all the necessary

procedures deemed appropriate to make a thorough diagnosis of the patient’s dental and oral facial needs.

Signature of Patient

Date

Doctor’s Signature - Orthodontist

Date

In order to provide our patients with the best financial terms possible, a soft credit check will be done.

*This will not affect your credit score in any way

Signature of Responsible Party____________________________________________Date____________________

(Office Use Only) Date Scanned: ____________________________

Child Patient And Responsible Party Information Form Page 3

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