New Child Patient Information - Stoll Orthodontics In Thornton, Westminster & Broomfield, CO

Patient Information

Is the patient a minor (under 18 years of age)?*

Yes

Patient's Name

Gender

Male

Female

Social Security Number

Date of Birth

Age

Home Address

City

State

Zipcode

Primary Phone Number

Primary Phone type

Home

Cell

Email Address

School

Grade

List any sports or extracurricular activities

Siblings (names and ages)

Parent/Guardian Information

Marital Status

Single

Married

Divorced

Widowed

Significant Other

Relationship to Patient

Name

Social Security Number

Date of Birth

Driver's License Number

Is your address the same as the patient's?

Yes

Home Address

City

State

Zipcode

Primary Phone Number

Phone Type

Home

Cell

Secondary Phone Number

Phone Type

Home

Cell

Other

Employer

Occupation

Add another parent / guardian?

Yes

Marital Status

Single

Married

Divorced

Widowed

Significant Other

Relationship to Patient

Name

Social Security Number

Date of Birth

Driver's License Number

Is their address the same as the patient's?

Yes

Home Address

City

State

Zipcode

Primary Phone Number

Phone Type

Home

Cell

Secondary Phone Number

Phone Type

Home

Cell

Other

Employer

Occupation

Emergency Contact Information

Emergency Contact Name (other than parent)

Phone Number

Relationship to Patient

Address

City

State

Zipcode

Person(s) OK to release appointment or medically related information to concerning child:

Name

Relationship to Child

Insurance Information

Do you have insurance?

Yes

Primary Insurance Information

Insurance Company

Phone Number

Group Number

Policy Number

Member ID

Policy Holder's Name

Relationship to Patient

Social Security Number

Date of Birth

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

Do you have secondary insurance?

Yes

Secondary Insurance Information

Insurance Company

Phone Number

Group Number

Policy Number

Member ID

Policy Holder's Name

Relationship to Patient

Social Security Number

Date of Birth

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

Dental History

General Dentist

Last Visit

How did you hear about our Practice?

Internet

Family / Friend

Physician

Other

Name of person referring (if applicable)

What are your main orthodontic concerns?

Has your child visited an orthodontist before?

Yes

When?

For What Reason?

Has your child's tonsils or adenoids been removed?

Yes

Has your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes

Does your child have any missing or extra permanent teeth?

Yes

Has your child ever had an injury to (select all that apply)?

None

Teeth

Mouth

Chin

Does your child have speech problems?

Yes

Please explain

Does your child currently or has your child ever had any of the following habits?

Clenching/Grinding Teeth

Lip Sucking/Biting

Mouth Breathing

Nail biting

Thumb/ Finger Sucking

Chewing/Eating Problems

Medical History

Is your child currently being treated by a physician?

Yes

Reason(s)

Physician's Name

Phone Number

Does your child have any allergies/sensitivities to medications or latex?

Yes

If yes, please list allergies:

Is your child currently taking any prescription or over-the-counter medications?

Yes

If yes, please list medications and dosages:

Has puberty and/or menstruation begun?

Yes

Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes

Has your child had any serious illnesses or operations?

Yes

If yes, please describe:

Has your child ever had a blood transfusion?

Yes

If yes, give approximate date(s):

Is your child pregnant?

Yes

Nursing?

Yes

Taking birth control pills?

Yes

Does your child have, or have they ever had, any of the following? (check all that apply)

None of these

Abnormal Bleeding

Anemia

Arthritis, Rheumatism

Artificial Heart Valve

Artificial Joints

Asthma

Back Problems

Blood Disease

Blood Transfusion

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Congenital Heart Defect

Cortisone Treatments

Cough, persistent

Coughing Blood

Diabetes

Difficulty Breathing

Drug/Alcohol Abuse

Epilepsy

Emphysema

Fainting

Fever Blisters/Herpes

Glaucoma

Headaches

Heart Attack

Heart Surgery

Heart Murmur

Heart Problems

Hemophilia

Hepatitis

High Blood Pressure

High/Low Blood Sugar

HIV/AIDS

Hospitalized for Any Reason

Jaw Pain

Kidney Disease

Liver Disease

Mitral Valve Prolapse

Pacemaker

Psychiatric Problems

Radiation Treatment

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Shingles

Shortness of Breath

Sickle Cell Disease/Traits

Sinus Problems

Skin Rash

Stroke

Swelling of Feet or Ankles

Thyroid Problems

Tobacco Habit

Tonsillitis

Tuberculosis

Ulcer

Venereal Disease

Authorization

Consent*

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.*

Signature of Parent / Guardian or Responsible Party*

Date*

New Child Patient Information Form

Patient Information

Parent/Guardian Information

Emergency Contact Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Dental History

Medical History

Authorization