Date

Patient Name

Birthdate

Have there been injuries to the face, mouth ot teeth? yes no

Has the patient ever sucked a thumb or fingers? yes no
If so, does he/she still have the habit? yes no
If no, at what age did he/she stop?

Have you been informed of any missing or extra permanent teeth? yes no

Does the patient suffer frequent headaches? yes no

Does the patient clench or grind teeth? yes no

Does the jaw ever hurt? yes no

Has the patient ever experienced any clicking or poping in the jaw joint?
yes no

Do you consider the patient to be a cooperative person? yes no

Has an orthodontist been consulted previously? yes no

Has either parent had orthodontic treatment? yes no

List any musical instruments played?

Are you concerned about your childs facial appearence? yes no
If yes, what is your concern?

Are you concerned about your child's teeth? yes no
If yes, what is your concern?

Please list andy special concerns?

Reason for your consultation?