First Visit — Child Non-Emergency | Ellis K. List, DDS, PA

PATIENT DETAILS

Patient's First Name

Patient's Last Name

Nickname

Patient's Address

City

State

Zip

Gender

Home Phone

Date of birth

Age

Race

Cell Phone

School/Employer

Grade/position

Work phone

How did you hear about our office

Family members treated in our office

Reason for Consultation

Previous Dentist

Date of last cleaning

Yes

Has the patient been examined by an orthodontist before?

GUARDIAN #1 / INSURANCE INFORMATION

Self

Spouse

Father

Mother

Stepparent

Other (specify)

Guardian's First Name

Guardian's Last Name

Home Phone

Address

City

State

Zip

Employer

Work Phone

Date of birth

Social Security Number

Cell Phone

Guardian's E-Mail

INSURANCE (IF APPLICABLE):

Company Name

Phone

Subscriber/Member ID

GUARDIAN #2 / INSURANCE INFORMATION

Yes

Is there a second guardian and / or additional insurance to add?

Self

Spouse

Father

Mother

Stepparent

Other (specify)

Guardian's First Name

Guardian's Last Name

Home Phone

Address

City

State

Zip

Employer

Work Phone

Date of birth

Social Security Number

Cell Phone

Guardian's E-Mail

ORTHODONTIC INSURANCE (IF APPLICABLE):

Company Name

Phone

Subscriber/Member ID

SLEEP / AIRWAY ISSUES

Yes

Does the patient tend to be a mouthbreather?

Yes

Does the patient snore at night?

Yes

Does the patient seem rested in the morning?

Yes

Is the patient often sleepy during the day?

Yes

Has the patient seen an Ear, Nose & Throat Specialist?

Yes

Is the patient using a sleep apnea device?

DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

Yes

Acid Reflux

Yes

ADHD/ADD

Yes

AIDS/HIV

Yes

Anemia

Yes

Arthritis

Yes

Asthma

Yes

Autism

Yes

Bone Disorders

Yes

Cancer

Yes

Cerebral Palsy

Yes

Chest Pain

Yes

Chronic Neck Pain

Yes

Clicking of Jaw

Yes

Jaw Pain

Yes

Cold Sores/Herpes

Yes

Diabetes

Yes

Down Syndrome

Yes

Endocrine Problems

Yes

Emotional Disorders

Yes

Epilepsy

Yes

Headaches

Yes

Heart Condition

Yes

Hepatitis

Yes

Ear Pain

Yes

Immune Problems

Yes

Kidney Problems

Yes

Low Blood Pressure

Yes

Muscular Disorders

Yes

Nervous Disorders

Yes

Organ Transplant

Yes

Osteoporosis

Yes

Painful Chewing

Yes

Periodontal Problems

Yes

Prolonged Bleeding

Yes

Rheumatic Fever

Yes

Scoliosis

Yes

Seizures

Yes

Sinus Problems

Yes

TMJ Problems

Yes

Tuberculosis

Yes

Do your gums bleed when you brush?

Yes

Is the patient seeing any other dental specialists?

Yes

Any dental restorations needing to be completed?

Yes

Have there ever been any injuries to the face, mouth or chin?

Yes

Have you ever lost or chipped any teeth?

Yes

Do you have any pain or soreness around your face, neck or back?

Yes

Is any part of your mouth sensitive to temperature or pressure?

Yes

Is the patient currently pregnant?

Yes

Have adenoids been removed?

Yes

Have tonsils been removed?

Yes

Currently taking any medications?

Yes

Are antibiotics necessary prior to treatment?

Yes

Allergies?

Yes

Any diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

Yes

Cheek, tongue or lip biting

Yes

Clenching Teeth

Yes

Fingernail Biting

Yes

Grinding Teeth

Yes

Tongue Sucking

Yes

Thumb Sucking

Yes

Tongue Thrusting

SIGNED CONSENT

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

Typed Name/Signature

Relationship to Patient

Date

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

By submitting this form you agree to the above mentioned consent statement

Your request has been sent -- we will be in contact with you shortly.

There was an error! Please phone our office.

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