"BRACES MAKE BEAUTIFUL FACES"

Thomas D. Jusino D.D.S., M.S.

"The Smile Engineer"

Child Medical History Form

Please download form, completely fill it out, and bring it to the initial visit appointment; or FAX (248) 476-3005

(There are 4 pages)

Today’s date:______________________

General Information

Patient name:_____________________ Age:_______ Date of Birth:________________

Nickname: _______________________ Sex: Male Female

Social Security #:_______________________

School: _______________________________ Grade: __________

Hobbies / Sports: _________________________________________________________

Musical Instruments played: ________________________________________________

Home Address:___________________________________________________________

______________________________________________ Tel.( )_________________

City State Zip

Name of person(s) accompanying child today? ________________ Relationship _______

Do you have legal custody of this child? Yes No

List brothers / sisters with age: ______________________________________________

Parent’s marital status: Single Married Separated Divorced Widowed

Mother’s name: _________________________________________

Mother’s Address:_________________________________________Tel.( )_________

Employer: ____________________________________ Wk. #: _____________

Office Address: _____________________________________ How long? ________

Father’s name: __________________________________________

Father’s Address: _________________________________________ Tel.( )_________

Employer: _________________________________________ Wk #: __________

Office Address: _______________________________________ How long? _______

Person Responsible for the Account:

Name: ____________________________ Relationship: _________________________

Billing Address: __________________________________________________________

Whom may we Thank for referring you?_______________________________________

Names of other family members seen by us?____________________________________

Family Dentist:______________________ Last Visit Date:_______________________

What are your concerns about your child’s teeth? ________________________________

________________________________________________________________________

Medical History:

Family Physician: _____________________ Last Visit Date: ______________________

Has your child had any of the following?

Y N Anemia Y N Heart surgery / Pacemaker

Y N Artificial Bones / Joints Y N Hemophilia / Abnormal Bleeding

Y N Artificial Valves Y N Hepatitis

Y N Asthma / Arthritis Y N High / Low Blood Pressure

Y N Blood Transfusion Y N HIV+ / AIDS

Y N Cancer / Chemotherapy Y N Hospitalized for Any Reason

Y N Congenital Heart Defects Y N Kidney Problems

Y N Diabetes / Tuberculosis Y N Mitral Valve Prolapse

Y N Difficulty Breathing Y N Psychiatric Problems

Y N Drug / Alcohol Abuse Y N Rheumatic / Scarlet Fever

Y N Emphysema / Glaucoma Y N Severe / Frequent Headaches

Y N Epilepsy/Seizures / Fainting Spells Y N Shingles

Y N Fever Blisters / Herpes Y N Sinus Problems

Y N Heart Attack / Stroke Y N Ulcers / Colitis

Y N Heart Murmur Y N Venereal Disease

Please discuss any medical problems that your child has had:_______________________ ________________________________________________________________________

Your child’s current general health is: Good Fair Poor

Y N Is your child currently under the care of a physician? If yes, reason ____________

Y N Is your child currently taking any medication? If yes, describe ________________

Y N Is your child allergic to any medications? (E.g.: aspirin, penicillin, etc.) If yes, ____________________________________________________

Y N Have adenoids or tonsils been removed? When?__________________________

Y N Has puberty begun?

Y N Has menstruation begun? (Girls)

Dental History:

Y N Has your child ever experienced pain/discomfort in the jaw joint (TMJ)?

Y N Does your child clench / grind their teeth?

Y N Have there been any injuries to the: Face Mouth Teeth Chin (please circle)

Y N Does your child brush his / her teeth daily? Y N Floss daily?

Y N Does your child have any missing or extra permanent teeth?

Your child’s current dental health is: Good Fair Poor

Does / did your child have any of the following habits: (Please circle all that apply)

Lip sucking/biting ; Mouth breathing ; Nail biting ; Speech problems ; Thumb/ Finger sucking ; tongue thrust

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 confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform any necessary dental services that my child may need during diagnosis and treatment with my informed consent.

____________________________________________________________

Signature Date

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

_____________________________________________________________

Signature Date

INSURANCE INFORMATION

Primary:

Insurance Company Name: _______________________________________

Insurance Company Address: ______________________________________

Insurance Company Phone #: _______________________________________

Group # (Plan, Local or Policy #): ___________________________________

Insured’s Name: ______________________________ Relationship _________________

Insured’s Birthdate: ____/____/____ Insured’s SS #: _______________________

Insured’s Employer: _______________________________________________________