Title* Master Miss

First Name*

Family Name*

Preferred Name*

Date of Birth*

Address*

Suburb*

Postcode*

Who is the child’s School Dentist or General Dentist

Unknown

How did you hear about us? / Referred by?*

Have we treated another family member?*

What are the main concerns that you would like orthodontics to accomplish?*

Has the child visited an orthodontist before?* Yes No

Name of previous Orthodontist*

Does the child require antibiotics before dental treatment? Yes No

Is the child receiving any medical treatment?*

Is the child currently taking any medications?*

History of major illness?*

Have you been informed of any missing or extra permanent teeth?*

Have there been injuries to the child’s face, mouth or teeth?*

Has the child ever had pain/ tenderness in their jaw joint (TMJ/TMD)?*

Does the child have any of the following habits?

Grinding Teeth

Mouth Breather

Chewing/Eating Problems

Finger/Thumb Sucking

Prolonged Bottle/Pacifier

Speech Problems

Will there be multiple parties financially responsible for the account? Yes No

Relationship to patient*

Title* Mr Mrs Miss Ms

First Name*

Family Name*

Address (if different to child’s)

Suburb

Postcode

Phone Home*

Phone Work

Mobile

Email*

Private Health Insurance Company

None

Relationship to patient*

Title* Mr Mrs Miss Ms

First Name*

Family Name*

Address (if different to child’s)

Suburb

Postcode

Phone Home*

Phone Work

Mobile

Email*

Private Health Insurance Company

None

In signing this form I acknowledge that this represents an accurate medical history. I will also supply my dentist with any relevant changes to this history as required. All medical information will be treated with complete professional confidentiality within the guidelines of the Privacy Act 12/01 and through the obligations health service providers have under the Professional and Ethical Codes of Practice.

Date*

Child Medical History Form

Patient Information Form CHILD (≤17 years)

Dental & Medical History

Guardian/ Parental Information For Account Purposes

Parent 1 Details

Parent 2 Details

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