Orthodontic Aquaitance Form
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1ORTHODONTIC AQUAINTANCE FORM
Date __________________
Demographic Information
Patient's Name __________________________________________ Name they would like to be called ______________________
Age ______ Birth date _________________ Social Security Number _____________________________ Sex (Circle one) F
M
Address _________________________________________________________________________________________________
Street
City
State
Zip Code
Home Phone Number _____________________ Names & ages of siblings ____________________________________________
Mother's Name _________________________________________ Social Security # _____________________ DOB __________
Mother's Employer _____________________________ Work Phone # _________________ Mobile Phone # _________________
Father's Name _________________________________________ Social Security # _____________________ DOB __________
Father's Employer ______________________________ Work Phone # _________________ Mobile Phone # _________________
Who has legal custody of patient? _________________________ Patient lives with: Mother Father Both Other ____________
Child's Physician _____________________________________ Phone # ________________ Date of last exam _______________
Child’s Dentist _______________________________________ Phone # ________________ Date of last exam _______________
Whom may we thank for referring you to us? _____________________________________________________________________
Please provide your email address if you would like to receive your appointment confirmations by email:
Email Address: ___________________________________________________________ (Mother / Father / Other_____________)
Health History
YES
NO
___
___
Has your child ever had a health problem? Please explain____________________________________________
___
___
Has your child ever been hospitalized? Please give reason and dates___________________________________
___
___
Is your child allergic to anything? _______________________________________________________________
___
___
Is your child currently taking any medications? Please give medication and reason ________________________
___
___
Were there any problems at birth? ______________________________________________________________
Please check if your child has been treated for any of the following:
___ Heart disease
___ Liver disease
___ Kidney disease
___ Anemia
___ Bleeding/transfusion
___ Asthma
___ Rheumatic fever
___ Seizures
___ Diabetes
___ Hepatitis
___ Cerebral palsy
___ Cleft lip/palate
___ AIDS
___ Depression
___ ADHD/ADD
___ Learning Disability ___ Speech/hearing
___ Other Problems (Please explain) ___________________________________
Reason for orthodontic consultation? ___________________________________________________________________________
Dental History
YES
NO
___
___
Has an orthodontist been consulted previously? Name ______________________________________________
___
___
Have you been informed of any missing or extra permanent teeth? _____________________________________
___
___
Have there been injuries to the face, mouth, or teeth? _______________________________________________
___
___
Does your child have pain with chewing, yawning or wide opening? ____________________________________
___
___
Does your child's jaw make noise and is pain associated with the sounds? _______________________________
___
___
Has either parent had orthodontic treatment? ______________________________________________________
Growth Data
YES
NO
___
___
Do your feel your child is still actively growing?
___
___
Females: Has menstruation started? What age: _____________
___
___
Males: Has there been a voice change or change in facial hair? ______________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I understand that it is my responsibility to inform this office of any changes in my child’s medical or dental status. I authorize
Dr. Christensen and the dental staff of Durham PDO to perform any necessary dental services that are needed during
diagnosis and treatment, including orthodontic records (models, photographs, and radiographs.) I understand that these
records may be used for both diagnostic and educational purposes.
Signature _________________________________ Relationship to patient _________________ Date__________
DURHAM PEDIATRIC DENTISTRY & ORTHODONTICS
121 W. Woodcroft Parkway, Durham, NC 27713 ~ Phone (919) 489-1543 ~ FAX (919) 489-2892 ~
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