Sex at Birth* Male Female

Patient’s Full Name*

Patient’s Phone*

Patient’s Date of birth*

Patient’s Age*

Patient’s Address*

Patient's Mother Full Name*

Patient's Mother Occupation*

Patient's Mother Phone*

Patient's Mother Email*

Patient's Father Full Name*

Patient's Father Occupation*

Patient's Father Phone*

Patient's Father Email*

Who is responsible for payment of fees?

Who recommended you to our practice?

Health Fund*

School*

Grade*

Has any other member of the family attended our surgery?* Yes No

If yes, Name of family member:

Name of Dentist*

Location of Dentist*

Have you ever had orthodontic treatment in the past or a previous orthodontic consultation? Yes No

If yes, details

Irregular teeth

Missing Teeth

Inability to chew effectively

Pain in the face or joints

Speech Defect

Facial appearance

Do you clench/grind your teeth? Yes No

When:

Do you have a nail biting habit? Yes No

Do you suck your thumb or fingers? Yes No

Do you normally breath through your; Your nose Your mouth

Has there been any major change in your health recently? Yes No

If yes, please give details

Are you currently taking any medications? Yes No

If yes, what is this medication taken for?

Have you ever had your tonsils/adenoids removed? Yes No

If yes, please give details

Do you smoke? * Yes No

If yes, how many cigarettes per day?

Do you take any medication for osteoporosis or cancer treatment? * Yes No

Do you take Fosamax or any Bisphosphonates? * Yes No

Has the patient been diagnosed with Autism? * Yes No

Has the patient been diagnosed with ADHD – Learning / Behavioural Difficulties? * Yes No

Has the patient been diagnosed with Anxiety, Depression, or mood Disorders? * Yes No

Have any accidents occurred that caused any of the following:

Tooth Loss

Chipping of any teeth

Facial Fractures

Discolouration of any teeth

Disturbance to jaw joints

I consent to my orthodontic records being used for dental education and training purposes. The identity of patients will not be disclosed. Yes No

I certify that the above medical history is accurate at this time. If there are any future changes, I will inform Dr Debora Harris

I understand that less than 24 hours notice given to cancel my initial scheduled appointment or failure to attend, the consultation fee of $150.00 will need to be prepaid prior to rescheduling my initial consultation.

Date*

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Child Medical History Form

Dental history

Orthodontic concerns

Dental trauma

Ready to begin your smile transformation?

Harris Orthodontics