Teenager Information

CHILD PERSONAL DETAILS

Last Name

First Name

Sex

D.O.B.

Address

Suburb

Postcode

Phone Number (Home)

Phone Number (Mobile)

Email

Mother's Name

Father's Name

Child living with

Siblings names and D.O.B.

Dentist's name

Doctor's name

PERSON RESPONSIBLE FOR ACCOUNT

Last Name

First Name

Address

Suburb

Postcode

Phone Number (Home)

Phone Number (Mobile)

Email

Relation

HEALTH FUND

WHO REFERRED YOU TO US?

MEDICAL HISTORY

Does your child have a health problem?

If yes, please list

Is there any history of serious illness, accident or operation?

If yes, please list

Is your child under a doctor's care for any problem at this time?

If yes, please list

Is your child taking any medication?

If yes, please list

Does your child have any allergies or drug sensitivities?

If yes, please list

Has puberty begun?

Has menstruation begun? (Girls)

DENTAL HISTORY

Has your child had an orthodontic consultation previously?

If yes, please give details

Has your child had any previous orthodontic treatment?

If yes, please give details

Have there ever been any injuries to the face, mouth, teeth or chin?

Has your child ever been informed of any missing or extra permanent teeth?

Has your child had any cyst or tumour of the jaws or gums?

Has your child had ever experienced pain or discomfort in the jaw joint?

Does your child brush his / her teeth daily?

Does your child floss his / her teeth daily?

Does your child have any of the following habits?

Clenching/Grinding

Nail Biting

Mouth Breathing

Lip Sucking/Biting

Tongue Thrusting

Thumb/Finger Sucking

Reason for seeking orthodontic treatment:

MEDICAL CHECKLIST

Arthritis

Asthma

Fainting or dizziness

Bleeding disorders

Bone disorders

Heart disease or murmur

Hepatitis

HIV+/AIDS

Cleft palate

Kidney/Liver Problems

Rheumatic/Scarlet Fever

Learning disabilities

Speech problems

Cancer or tumour

Convulsions/Epilepsy

Diabetes

Hearing problems

Endocrine problems

Emotional problems

Syndromes

Operations

Tuberculosis

I understand that the information I have provided 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 to 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.

I accept the terms & conditions

8/3 Rosewood Drive

Rural View, Mackay 4740

(07) 4840 2832

Call us today!

Opening Hours

Mon - Fri: 8:00 - 17:00