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Child medical history

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Client details:

Title *
First name *
Middle name
Last name *
Gender *
Date of birth *
Address *
Suburb *
Postcode *
Phone *
Medical practitioner
Family dentist
Referring dentist

Trauma

Have you ever had an accident involving teeth or jaw? *
Have you ever had clicking, noises, or pain in your jaw joints? *

Medical history

This may affect the orthodontic treatment. Please circle the correct answer and provide details when necessary.

Allergy to latex *
Heart or Kidney Disease *
Asperger’s, Autism, ADD, ADHD *
Allergies *
Asthma *
Blood pressure *
Anesthesia complications *
Psychiatric or Psychological care *
Diabetes, Epilepsy, Goitre etc *
Is there a possibility that you could be pregnant *
Prolonged bleeding after injury *
Serious operation *
Are you taking any medication *
Hepatitis or HIV *
Other *
Congenital heat disease or rheumatic fever *
Do you require antibiotic cover for dental procedures *
Prone to fainting *
Further details, if necessary

Sleep disturbance scale

At Smile Team Orthodontics we believe that all of our clients (both children and adults) should be screened before they consider orthodontic treatment because our treatment recommendations may differ in the presence of sleep apnea.

What is Obstructive Sleep Apnea? Sleep Apnea occurs when the walls to the throat close during sleep, causing breathing to stop. Once the brain registers that it is not breathing, the sleeper usually wakes up, rouses and the throat opens again, then they drift back to sleep. The person effected by sleep apnea, in most cases, does not realise they have even woken. It also causes decreased Oxygen Intake. This means the brain, heart and nervous system are not receiving their required time to rest and oxygenate. The pattern can repeat itself hundreds of times every night. One of the side effects of Sleep Apnea is Cardiac Problems. Also drivers with sleep apnea have 8 times the risk of car accidents.

Sudden Cardiac Death during sleep occurs more commonly in patients who have Obstructive Sleep Apnea.

EXTRACT FROM THE BRUNI SCALE - for 16 years and under. This questionnaire will allow your orthodontist to have a better understanding of the sleep-wake rhythm of your child and of any problems in his/her sleep behavior. Answer every question; in answering, consider each question as pertaining to the past 6 months of the child’s life.

Please answer the questions by circling or striking the number 1 to 5.

The child has difficulty in breathing during the night *
The child gasps for breath or is unable to breathe during sleep *
The child snores *

Referral

Have you had another member of your family treated in this practice? *
If YES what is the family member’s name?
Do you have a referral? *
Have you had a dental check up in the last 12 months? *

How did you hear about Smile Team Orthodontics? *

Please select ONE that may apply and provide details when necessary in box below.


If Specialist, please specify
If Friend, please name
If Member of Staff, please specify
If Relative, please name
If Other, please specify

Parent/Guardian

Complete the information for Parents/Guardians overseeing the client's appointments, scheduling, and treatment. Alternatively, See the split payment options outlined in the billing section

Parent/Guardian 1

Title *
First name *
Last name *
DOB *
Address *
Phone *
Email *
Relationship to client
Are you responsible for the finances? *
Are you the primary carer? *

Parent/Guardian 2

Title *
First name *
Last name *
DOB *
Phone *
Email *
Address *
Relationship to client
Are you responsible for the finances? *
Are you the primary carer? *
For billing purposes will payments be split between responsibly parties or third parties? *

If yes, please complete below details of the second party/third party responsible for the account.

Name
Email
DOB
Phone
Address
Is this party authorized to receive information regarding the client’s treatment and bookings?
Date

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