Case history Form For 18 years and under, have parents complete "*" indicates required fields Patient's Name* Date Dentist Name* Téléphone*Date of last dental examination* DD slash MM slash YYYY Date of last dental cleaning* DD slash MM slash YYYY Previous treatments Does he have cracks or pain in the jaw?* Yes No Have the front teeth ever been chipped or broken?* Yes No SPECIAL QUESTIONS regarding the patient:Does he breathe through his mouth?* Rarely Occasionally Always Does he have frequent tonsillitis?* Yes No Does he often have colds?* Yes No Does he have difficulty chewing or swallowing?* Yes No Does he suffer from headaches?* Yes No Does he snore?* Yes No Is he often tired, does he lack attention in class?* Yes No Has he ever been treated by an allergist or ENT?* Yes No If yes, when?* By who ?* Tonsils removed ?* Yes No Vegetation removed?* Yes No Age of eruption of the first primary tooth:* Age of eruption of the first permanent tooth:* HABITSThumb sucking up to the age of: Sucking finger(s) up to the age of: Teeth grinding:* Yes No Bad swallowing:* Yes No Lip sucking:* Yes No Other habits (pencil in mouth, object?):* Yes No Others, specify: EXPERIENCESHas he ever had a bad experience with a dentist?* Yes No If yes which one? Has he ever had an orthodontic examination or treatment?* Yes No If yes, when? By who? Dr. Kind of treatments: OTHERSIs the patient followed by an osteopath?* Yes No If yes which? Did we miss any medical or dental issues?* Yes No If yes which? Signature of patient (or parent if minor)*
