Child Medical Health Questionnaire

This form will take several minutes and your progress can't reliably be saved for later if it's left unfinished. Before starting, please ensure you can complete it in one attempt. Your completed questionnaire will only be sent to us when you press the final Submit button.

We take security & privacy seriously. When you fill out this form online, your details will be stored in our secure database and will not be sent anywhere by email.

If you have any questions, please phone our office during regular business hours (found on this page).

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Patient Information

Patient's name *

First

Last

Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Patient's phone number

Enter if applicable. Parent / guardian details will be collected later.

Age *

Birthdate (DD/MM/YYYY) *

Gender *

Female
Male
Other

Note: Our medical software is limited to the options of Male and Female, and choosing one of those 2 options is a requirement. If the patient identifies otherwise, we sincerely apologize that we aren’t able to record this accurately. Please choose which gender we should put on the patient file, and you can also specify their pronouns, below.

Gender (for patient file) *

Female
Male

Pronouns *

She / her
He / him
Let me type...

This helps us understand the best way to address the patient.

How shall we address the patient? *

Do you currently have a dentist? *

Dentist's name *

Dentist's office phone number *

This ensures we find the correct dentist with the provided name.

Who may we thank for referring you to our office? *

Dentist
Patient
Other

Patient's name *

Please specify (other) *

Who is legally permitted to give consent? *

Mother
Father
Both
Other

Please specify (other) *

Patient lives with... *

Both parents together
Both parents separately
Mother
Father
Other

Please specify (other) *

Party Responsible for the Patient

Caregiver's name *

First

Last

Relationship to patient *

Same address as patient? *

Caregiver's address *

Address Line 1

Address Line 2

City

Province

Postal Code

Mobile phone *

Home phone

Business phone

Email *

Occupation

Medical History

General health: *

Excellent
Good
Fair
Poor

Details of your general health: *

Is the patient taking any prescription or non-prescription drugs? *

Medication details: *

Is there any history of allergies? (i.e. metals, environmental, medications) *

Allergy details: *

Is there a history of a heart murmur or mitral valve prolapse? *

Heart condition details: *

Does the patient require antibiotics prior to dental appointments? *

Is there a history of conditions that could affect the immune system? (i.e. leukemia, autoimmune diseases, HIV) *

Immune system details: *

Is there a tendency to bruise easily or bleed for a prolonged period of time after being cut? *

Bruising / bleeding details: *

Does the patient currently smoke, vape or use tobacco products? *

Type of product and frequency of use *

Is there a history of emotional disorders or mental health? *

Mental health details: *

Is there a history of eating disorders? *

Eating disorder details: *

(If applicable) Is the patient pregnant or is there a possibility that they may be? *

Pregnancy details: *

**Important** Are there any privacy concerns regarding the knowledge of your pregnancy, such as with the party responsible for your account? You may also specify how many weeks/months pregnant, or your due date.

Dental History

Why are you seeking an orthodontic evaluation? *

Has any other family member had orthodontic treatment? *

When was the most recent dental visit? *

When were the last dental x-rays taken? *

Thumb / finger sucking habit? *

Yes, presently
Yes, in the past
No

Finger sucking details: *

e.g. daily, only at night, and which fingers

Finger sucking details: *

e.g. daily, only at night, and until what age

Accidents/trauma involving the teeth/jaws/nose? *

Nature of injury (incl. which teeth, if applicable), when it happened, and the healing outcome. *

Tooth extractions? *

(e.g. wisdom teeth, or otherwise)

Which teeth? When? *

Is the patient being monitored by a dental specialist? (e.g. gum specialist) *

Doctor's name *

Previous orthodontic consultations? *

Doctor's name *

Previous orthodontic treatment? *

Previous orthodontic treatment details: *

Please list anything else not mentioned above regarding the past dental history

Please list any sports, musical instruments or hobbies

Note: As part of the Regulated Health Professions Act (PIPEDA), we are required to ask for permission to be able to correspond with other associated healthcare personnel (i.e. family dentist, physician)

Do you authorize permission, as per the statement above? *

Please provide details as to why not *

Signature *

Additional comments (optional)