Child Health History - Joseph LaPonzina Orthodontics

  • CHILD PATIENT INFORMATION

  • Date
     - -
  • Birthdate*
     - -
  • Sex*

  • Parent/ Guardian Information

  • DOB
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • DOB
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parents Marital Status *

  • Insurance Information

  • PRIMARY

     

     
     

  • SECONDARY

  • Dental History

  • Frequency of Checkups
  • Date of last visit
     - -
  • Is there any unfinished care to be completed with your child’s dentist?*
  • Have teeth (either baby or permanent) been removed?*
  • Has your child had any face or dental injuries?*
  • Does your child play any musical instrument?*
  • Was an orthodontist consulted previously?*
  • Does the patient desire orthodontic treatment?*
  • Please check if there is a history of:

  • Medical History

  • Last Visit
     - -
  • Is child in good health?*
  • Child taking any drugs/medication?*
  • Allergies to any medication(s)?*
  • Food or Other Allergies? (i.e. Latex)*
  • Rheumatic fever, heart disease, murmur?*
  • Tonsils and/or adenoids removed?*
  • Any learning/emotional disorders?*
  • Serious illness or hospitalization?*
  • Powered by Jotform SignClear
  • Date*
     - -
  • Should be Empty: