Adolescent Intake Form
Please complete the orthodontic intake questions for your child
1. About Your Child
Today's Date
First Name
MI
Last Name
Email
Child's Birthdate
Gender
Male
Female
Street Address
Street Address Line 2
City
State
Zip Code
Grade
Best Phone Number
2. Accompanying Adult and Dentist
Accompanying Adult First Name
Accompanying Adult Last Name
Relationship to Child
Do you have custody of this child?
Yes
No
Whom may we thank for referring you?
General Dentist
Last Dental Visit
3. Parent / Guardian and Responsible Party
Parent / Guardian 1
Relationship
Select...
Mother
Father
Step Parent
Guardian
First Name
Last Name
Email
Phone
Birthdate
Parent / Guardian 2 (if applicable)
Relationship
Select...
Mother
Father
Step Parent
Guardian
First Name
Last Name
Email
Phone
Responsible Party
First Name
Last Name
Relationship to Child
Phone
Is the address the same as the child's?
Yes
No
Street Address
City
State
Zip
4. Orthodontic Insurance
Do you have orthodontic coverage?
Yes
No
Insurance Company Name
Group #
Policy #
Policy Owner's First Name
Policy Owner's Last Name
Relationship to Child
Policy Owner's Birthdate
5. Medical and Dental History
What are your concerns regarding your child's teeth?
Has your child previously had orthodontic treatment?
Yes
No
If yes, when?
Has your child ever had any problems with their jaw (TMJ)?
Yes
No
Have there been any traumatic injuries to the face, mouth, or teeth?
Yes
No
Has your child ever had permanent teeth removed?
Yes
No
Does your child breathe through their mouth?
Yes
No
Is your child currently under a physician's care?
Yes
No
Child's Physician
Physician Phone
Has puberty started?
Yes
No
Please describe your child's general health
Good
Fair
Poor
Please list all medications your child is currently taking
Please list any medical conditions your child has
Allergies (check all that apply)
Penicillin
Aspirin
Latex
Metals
Local Anesthesia
Other
None
Has your child ever had any of the following medical problems?
AIDS/HIV
Anemia
Arthritis
Asthma
Blood Disease
Cancer
Diabetes
Epilepsy
Fainting
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Disease
Liver Disease
Rheumatic Fever
Seizures
Stroke
Thyroid Problems
Tuberculosis
Please discuss any conditions checked above
Has your child ever experienced any of the following?
Thumb/Finger Sucking
Pacifier Use
Tongue Thrust
Nail Biting
Teeth Grinding
Jaw Clicking
Difficulty Chewing
Lip/Cheek Biting
Emergency Contact Name
Emergency Contact Phone
6. Consult Questions
Has the patient already seen a general dentist, or do they need to see one first?
Already referred by general dentist
Needs to see general dentist first
Are there any cavities or unfinished dental work still needing treatment?
Yes
No
What kind of scheduling works best?
Weekdays are okay
Weekdays only
Saturday only
Does the patient have any sensitivity, habits, or concerns we should know about?
Are you interested in aligners or comparing braces and aligners?
Braces only
Aligners only
Compare both
Not sure
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