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858.487.0173 15525 Pomerado Rd. Ste. C4
Poway, CA 92064-2426 info@alignorthosd.com
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Child Patient Form

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Dr. Nguyen is a graduate of the University of Montreal. She completed her general practice residency at Kingsbrook Jewish Medical Center...

Align Orthodontics > About Us > Child Patient Form

Please check the required fields

Patient's First Name:
Patient's Last Name:
Prefers to be called:
Please list all persons who have financial or custodial responsibility for the patient and provide their relationship to the patient and contact information if different from patient's contact information:
DENTAL (Mark All That Apply: Check box for YES, Leave blank for NO)

Has your child ever experienced an unfavorable reaction to dentistry?
Have you been informed that your child has of extra or missing teeth?
Is any part of your child's mouth sensitive to temperature/pressure?
Does your child brush his/her teeth daily?
Does your child floss regularly?
Does your child have any kind of finger, thumb/tongue habit?
Has your child ever had any pain, tenderness, clicking, or popping in his/her jaw (TMJ/TMD)?
Does your child clench/grind his/her teeth?
Does your child have any difficulty chewing/swallowing food?
Does your child's bite feel uncomfortable?
Indicate your child's feelings/attitude towards having orthodontic treatment:

Wants treatment
Unwilling but agrees
Understands treatment is necessary
Uncooperative
Has an orthodontist been previously consulted?
Are you aware of any dental work that needs to be completed prior to orthodontic treatment?
Date of your child's most recent dental examination:

/ /
Other dentists/dental specialist that are being seen and reason:
Have there been any injuries to your child's face, mouth, teeth or chin? If yes, please explain:
Have any teeth been removed by extraction? If yes, please explain:
Has anyone else in your family received orthodontic treatment? If yes, how did they feel about the results?
MEDICAL - Has your child ever had any of the following diseases or medical conditions? (Check all that apply)

Abnormal Bleeding/Hemophilia
Anemia
Arthritis
Asthma/Hayfever
Blood Disorders
Bone Disorders
Congenital Heart Defect
Depression/Mental Illness
Diabetes
Dizziness
Endocrine Problems
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV+/AIDS
Kidney Problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor/Cancer
Does your child have any other medical condition not described above? If yes, please explain:
Has your child had an allergic reaction to any of the following? (Check all that apply)

Aspirin
Codeine
Dental Anesthetics
Erythromycin
Latex
Penicillin
Tetracycline
Metals
Others
Please list any other medications to which your child has had an allergic reaction:
Has your child ever had to take antibiotics prior to a dental visit/checkup?
Has your child been diagnosed with any emotional disorders, including ADD/ADHD? If yes, pelase list any medications:
Please list all other medications that your child is currently taking:
Is your child currently under the care of a physician? If yes, please explain:
Please explain any medical problems that your child has had in the past:
I have read and I understand the above questions. I will not hold Dr. Henry or any member of his staff responsible for any errors or omissions that have been made in the completion of this form. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any later changes to the history record or medical/dental status. We will discuss your child's treatment with parents/legal guardians/person(s) financially responsible for his/her treatment and referring doctors/dentists for the furtherment of his/her treatment.
Signature of parent/legal guardian
Date

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858.487.0173 Dr. Nguyen 15525 Pomerado Rd, Ste. C4
Poway, CA 92064-2426 info@alignorthosd.com

Serving All of San Diego:

We are pleased to serve orthodontic patients from all over San Diego, CA Including: Poway, Rancho Bernardo, Scripps Ranch, Ramona, Carmel Mountain Ranch, Rancho Penasquitos and 4S Ranch.

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Orthodontic Treatments
Patient Education
Before & After Gallery
Invisalign
Emergencies
Contact Us

Align Orthodontics 15525 Pomerado Rd, Ste. C4
Poway, CA 92064-2426 858.487.0173 info@alignorthosd.com

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