Child Health & Business Questionaire Form - Alberta - Canada Page 2
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29.
Please list any illness that required medical attention that your child
Has Had:_____________________________________________________________________________________________
____________________________________________________________________________________________________
Currently has:_________________________________________________________________________________________
____________________________________________________________________________________________________
10.
Please check any of these medications your child may have taken in the past year:
Penicillin
Blood thinners
Digitalis
Other___________
Cortisone
Tranquilizers
Thyroid
Nitroglycerin
Dilantin
Aspirin
__________________
11.
Please check any of these items that your child has had a bad reaction to:
Local Anesthetics
Codeine
Insulin
Barbituates
Ibuprofen Penicillin
Aspirin
Iodine
Other_________________
Does your child suffer frequent colds?…………………………………………………………………..
12.
YES
NO
Does your child have difficulty breathing through the nose?…………………………………………….
13.
YES
NO
Has your child had abnormal bleeding associated with previous extractions, surgery or trauma?………
14.
YES
NO
15.
Has your child (at any age) had an injury to their head, neck, face, teeth or chin?
YES
NO
(ie. Stitches, concussions, whiplash)
If Yes, explain:______________________________________________________________
Is there any other information we should know about your child’s health or previous dental treatment?
16.
YES
NO
If Yes, explain:______________________________________________________________
17.
Does your child have a metal or latex sensitivity or allergy?……………………………………………
YES
NO
18.
Has your child had a recent exposure to any communicable infectious diseases?
YES
NO
(measles, chicken pox or Tuberculosis)
19.
In the last 24 hours has your child had a new cough, shortness of breath, fever, chills, diarrhea or other flu-
like symptoms? ……………………………………………………………………………………………… YES
NO
What is the main reason for seeking orthodontic care for your child? ________________________________________________
PARENTAL CONSENT FOR A MINOR
I AUTHORIZE ALL NECESSARY DENTAL RECORDS AND EXAMINATIONS TO BE RENDERED FOR
______________________________.
(Patient’s Name)
Signature: _____________________________ Relationship: ______________________
Date: ______________________
(Parent or Guardian)
INSURANCE INFORMATION
Policy Holder Name
___________________________________
(2) ______________________________________
Policy Holder Birthdate ___________________________________
______________________________________
Insurance Company
___________________________________
______________________________________
Group/Policy
___________________________________
______________________________________
I.D./Cert.No
___________________________________
______________________________________
AUTHENTIC ORTHODONTICS
#540, 19489 Seton Cr S.E. Calgary, AB. T3M 1T4
PH 403-523-9101 FAX 430-523-9102
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