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Child Patient Personal Information

Parent/Guardian Information

Dental History

Have You Seen an Orthodontist Before:
Have you ever required antibiotics or other medications prior to dental treatment?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Jaw joint problems?
Grinding and/or clenching of teeth?
Thumb/finger sucking?
Injury to face or teeth?
Tongue position or swallowing problems?
Tonsils or adenoids removed?
Speech/articulation problems?
Mouth breathing more than nose breathing?

Medical History

Are you currently under medical care?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Nickel/Metal allergy?
Latex allergy?
Rheumatic fever?
Epilepsy or Seizures?
Hereditary problems?
Asthma?
Headaches?
Hepatitis?
Heart murmur?
Heart problems?
H.I.V. positive?
Diabetes?
Anemia?
Prolonged bleeding?
Snoring or Sleep Apnea?

Dental Insurance Information

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