Medical Dental History Form for Patients Under Age 18

PATIENT

PARENT/GUARDIAN

Father's Information
Mother's Information

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

Other physicians/health care providers being seen now:

MEDICAL HISTORY

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (DKU).
Now or in the past, has your child had:

Has your child had allergies or reactions to any of the following?

DENTAL HISTORY

Now or in the past, has the patient had:

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.

FAMILY MEDICAL HISTORY

Have the parents or siblings ever had any of the following health problems? If so, please explain.

RELEASE AND WAIVER

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

MEDICAL HISTORY UPDATES