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Torque Orthodontics (07) 4951 4100

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Torque Orthodontics / Patient info / New patient forms / New Patient - Child form

Personal medical information

Kindly fill in form for your Medical history or download our form below.

Fields marked * are required.

PERSONAL & MEDICAL HISTORY - CHILD

Patient’s Full name* Patient’s preferred name* Date of birth

Gender* Address Mobile Number* Mobile Number 2* Home Number* Postcode Email Parent / Guardian* Father's Full Name Father's Occupation Mother's Full Name Mother's Occupation Siblings Financially Responsible person's name Financially Responsible person's address* Email for monthly statements Name of health fund* General Dentist’s name* Family Physician’s name* Date of last dental check up

Reason for seeking orthodontic treatment Do you feel there is need for orthodontic treatment? Yes No If “YES” please provide details Has the patient had an orthodontic consultation previously? Yes No If “YES” please provide details Has the patient had any previous orthodontic treatment? Yes No If “YES” please provide details Has the patient had any injuries to the teeth (both baby & permanent), face, jaws or chin? Yes No If “YES” please provide details Has the patient had any cysts or tumors of the jaws or gums? Yes No If “YES” please provide details Has the patient been informed of any missing or extra permanent teeth? Yes No If “YES” please provide details Has either parent had orthodontic treatment? Yes No If “YES” please provide details Is the patient in good health? Yes No If “No” please provide details Have you ever had any serious medical or surgical problems? Yes No If “YES” please provide details Is the patient under any physicians care for any problems at this time? Yes No If “YES” please provide details Does the patient have any allergies? (eg Latex, Medicines, Foods or Drug Sensitive etc.) Yes No If “YES” please provide details Is the patient taking any medication? Yes No If “YES” please provide details

Is the patient suffering from (or have you ever had) any of the following?

Rheumatic fever

Heart Disease / Heart Murmur

Stroke

High/Low blood pressure

Diabetes

Fits/ Epilepsy/Fainting/Dizziness

Asthma- Mild, Moderate, Severe

Rheumatism

HIV/AIDS

Hepatitis

Any blood disorder

Joint problems /replacement

Disorder of the stomach, bowel or digestive system

Cancer/Tumors (Benign/ Malignant)

Osteoporosis

Does the patient have any medical conditions that requires ANTIBIOTIC COVER for dental treatment? Yes No Are there any other medical or physical conditions we need to know about? (e.g. Learning difficulties, Anxiety, Hearing impairment, Autism Spectrum Disorder, Speech, Bed wetting etc.) Yes No If “YES” please provide details Has the patient reached puberty? Yes No Girls (Has menstruation started) Age menstruation commenced Boys (Has there been a change in voice?) Yes No

Please note that we only treat you according to the information you have provided for us.

If there is any information that you would not like discussed but is relevant to your dental history, please detail. We are most appreciative if you take the time to let us know how you heard about our office.* Why you chose treatment with the team at Torque Orthodontics. Name Date*

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Torque Orthodontics

Level 2, 56 Gordon Street
Mackay, QLD 4740
Phone: (07) 4951 4100

© Copyright 2016 Torque Orthodontics. All rights reserved.

Book a consultation
Patient info
Treatments
Orthodontic care
Smile gallery
- Invisalign before and afters
- Braces before and afters
About us
Contact us

Fix my smile