Children's Medical History Form - Lifestyle Orthodontics

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Patient Information

Title

Patient's First Name(Required)

Patient's Surname(Required)

Date of Birth(Required)

Address(Required)

Street Address City State Postcode

Patient Mobile (if applicable)

Home Telephone

Sports and Hobbies

Person responsible for the account

Responsible Party Name(Required)

Responsible Party Address(Required)

Street Address City State Postcode

Responsible Party Email Address(Required)

Do you have private health insurance that covers Orthodontic treatment?(Required)

Yes

Health Fund Provider

Dental History

Do you have a current general dentist?(Required)

Yes

Name of General Dentist

Address of General Dentist

Street Address City State Postcode

When was the last Dental check up and professional cleaning?(Required)

Has the patient had previous Orthodontic Treatment?(Required)

Yes

Name of Previous Orthodontist

Date Orthodontic Treatment was completed

Type of treatment undertaken

Were you referred by another health professional?(Required)

Yes

Name of referring doctor

What is your / your child's primary concern?(Required)

What treatment are you interested in?(Required)

Patient health history (select all that may apply)

Asthma

Arthritis

AIDS/HIV

Anaemia

Blood disorders

Cold sores

Diabetes

Emotional Stress

Epilepsy

Heart valve

Hepatitis A/B/C

Joint replacement

Kidney / Liver disorder

Sleep apnea / snoring

Prolonged bleeding

Does the patient smoke?(Required)

Yes

Other

Is the patient pregnant?(Required)

Yes

Does the patient suffer from sleeping conditions such as Obstructive Sleep Apnea or loud snoring?(Required)

Yes

Sleep Disturbance Questionnaire

This questionnaire will allow your orthodontist to have a better understanding of the sleep-wake rhythm of your child and of any problems in his/her sleep behaviour. Answer every question; in answering, consider each question as pertaining to the past 6 months of the child’s life.

Please answer the questions by choosing the number 1 to 5.
1 = Never
2 = Occasionally (once or twice per month or less)
3 = Sometimes (Once or twice per week)
4 = Often (3–4 times a week)
5 = Always (Daily)

The child has difficulty breathing in the night(Required)

The child gasps for breath or is unable to breathe during sleep(Required)

The child snores(Required)

Allergies

Is the patient allergic to any of the following?

Codeine

Plastic

Sulpher

Metal

Penicillin

Latex

Please list any other drugs or metals that the patient is allergic to:

Please list any other medical condition / congenital abnormalities that the patient has/is being treated for:

Please list any medications the patient may be taking:

Consent for use of records

We may use some of your photographs and records made in the process of examination, treatment and retention for promotional use, research, in study groups, seminars or education purposes as this may provide benefit to other patients. Please advise if you do not wish for this information to be disclosed.

Do you consent for your photographs and records to be used?(Required)

I consent

I do not consent

Patient / Responsible Party Name(Required)

First Last

Date(Required)

Signature(Required)

Your Name
Your Name
Your Name

Signature

Who may we thank for referring you?

Name(Required)

First Last

Consent(Required)

I affirm that the information given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in this medical history.(Required)

Signature of parent / legal guardian.(Required)

Your Name
Your Name
Your Name

Date(Required)

Children’s Medical History Form

Patient Information

Person responsible for the account

Dental History

Sleep Disturbance Questionnaire

Allergies

Consent for use of records

Signature