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Confidential Youth Patient Health History Form

Responsible Party Information
Name of Responsible Party
Spuse's Name
Responsible Party Information
Patient Name
Gender
Insurance Information
Policy Holder
Do You Have Dual Coverage?
If yes, please fill out the following
Policy Holder
Emergency Contact Information
Dental and Medical History
Answer yes if applicable now or in the past:
Any past orthodontic evaluations, consultations or treatment
Any injuries to face, mouth, teeth
Plays a musical instrument
Tonsils/Adenoids removed
Been informed of any missing or extra permanent teeth
Jaw joint pain or tenderness
Floss his/her teeth daily
Is your child currently under the care of a physician
If yes..
Has your child begun puberty
If patient is a girl, has menstruation begun
Please describe your child's current physical health
Other allergies
Latex
Metals/Nickel
Plastics
Has your child had any of the following medical conditions?
Abnormal bleeding

ADD / ADHD

Any hospital stays or surgical operations

Heart murmurs

Artificial joints, bones, or valves

Hepatitis

HIV / AIDS

Kidney or liver problems

Rheumatic / Scarlet fever

Convulsions / Epilepsy

Diabetes

Handicaps / Disabilities

Hemophilia

Asthma

Cancer

Congenital Heart Defect

Lupus

Tuberculosis

Has your child ever experienced any of the following?
Clenching / Grinding teeth

Nursing bottle habits

Mouth Breather

Nail Biting

Speech Problems

Lip Sucking / Biting

Thumb / Finger Sucking

Tongue Thrust

 

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Office Locations

ORLAND PARK
15100 S. LaGrange Rd.,
Orland Park, Illinois 60462
ph. 708.349.1740
OAK FOREST
5950 W. 159th St.,
Oak Forest, Illinois 60452
ph. 708.687.4280