Contact Details Patient's Name Preferred Name Street Address Street Address line 2 City State NSWACTQLDVICSAWANTTAS Postcode School Attended Home Phone Mobile Phone Email Date of Birth Referral Details Who recommended you to this practice? Dentist’s Name Dentist’s Suburb Responsible Party’s Details First Name Surname Street Address Street Address line 2 City State NSWACTQLDVICSAWANTTAS Postcode blank Medical History Please indicate any serious illnesses or allergies Asthma Epilepsy Cleft Lip HIV+ Heart condition Diabetes ADHD Blood Clotting Problems Bone disorders (eg Osteoporosis, Arthritis) Other Please specify other illnesses or allergies Is the child taking any medication? Yes No What is the medication for? Maturation Child's gender: Female Male Has she reached menstruation/puberty? Yes No At what age? Has his voice changed? Yes No At what age? Has there been rapid growth recently? Yes No Sibling's maturation rate (brothers and sisters early or late growers): Early Average Late Height of father (in cm) Height of mother (in cm) Dental History Has there ever been a hard knock to, or fracture of, teeth or jaws? Yes No Please give details of the injury that occured Any jaw joint problems or clicks? Yes No Have any of the teeth had root canal therapy or very deep fillings? Yes No Orthodontics In your own words, describe the problem with the jaws or teeth as you see it: How would you describe your child's temperment? Parent's concern re orthodontic problem: Very Concerned Concerned Indifferent Opposed Patient's concern re orthodontic problem: Very Concerned Concerned Indifferent Opposed Did the child suck thumb or fingers after age 4 years? Yes No Does the child still suck thumb or fingers? Yes No Does the child have any particular mouth habits or play a wind instrument? Is the child a mouthbreather? Yes No Has the child had speech therapy? Yes No When? Submit Thank you for completing our patient form. The form has been sent. An error occured. Book your appointment with us today Don’t wait any longer to celebrate your new smile! Book Now
