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(08) 9258 8440

(08) 9758 8150

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Cannington (08) 9258 8440

Margaret River (08) 9758 8150

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- Cannington
- Margaret River

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Medical And Dental History
(Child/Adolescent Form)

To enable us to diagnose and treat your child at the highest standard of care, please answer the following questions as accurately as possible.

Medical And Dental History
(Child/Adolescent Form)

Patient details

All fields must be completed

Patient First Name*

Patient Last Name*

Gender

Male

Female

Not Listed

If not listed, please give preferred gender identification

Preferred Pronoun

He

She

They

Other

If not listed, please give preferred gender identification

Mother's Name*

Father's Name*

Patient DOB*

Patient Year at School

Name of Person completing questionnaire

Relationship to Patient: Mother / Father / Guardian / Other

Contact Mobile Phone

Contact Email*

Address

Suburb

Postal Code

Parent's contact phone

Name of Private Health Insurance Provider (if any)

Name of General Dentist/Dental Clinic

Has your dentist given you a referral to see an orthodontist?

Yes

No

*If yes, please ensure a copy is sent to us before your appointment.

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Has/Is your child

Previously had or currently having any chronic health problems?

Yes

No

If yes, please describe

Currently under the care of any specialist medical practitioners?

Yes

No

If yes, what for?

Currently taking any regular medications?

Yes

No

If yes, please list

Allergic to anything?

Yes

No

If yes, please list

Have any airway/breathing/snoring/sleep apnea issues?

Yes

No

If yes, please describe

Had their tonsils and/or adenoids removed?

Yes

No

If yes, when

Does your child have any of the following health issues?

ADD/ADHD

Yes

No

Diabetes

Yes

No

Asthma

Yes

No

Epilepsy

Yes

No

Autism/Aspergers

Yes

No

Heart or Blood Pressure Problems

Yes

No

Blood/Bleeding Disorders

Yes

No

Hepatitis B/HIV

Yes

No

Cleft Lip or Palate

Yes

No

Juvenile Arthritis

Yes

No

Congential Birth Defects/Syndromes

Yes

No

Kidney or Liver problems

Yes

No

Depression or other psychological problems

Yes

No

Speech, learning or hearing problems

Yes

No

Please note any relevant information or other medical conditions not listed above that should be brought to our attention

Dental History - Has your child had any of the following?

Chronic Mouth breathing

Yes

No

Jaw Joint (TMJ) clicking or locking

Yes

No

Clenching or Grinding of Teeth

Yes

No

Persistent Thumb or Finger Sucking

Yes

No

Dental or Facial Trauma

Yes

No

Previous Orthodontic Treatment

Yes

No

Frequent Mouth Ulcers

Yes

No

Previous Speech Therapy

Yes

No

Gum Disease

Yes

No

Tooth Decay, Fillings or Extractions

Yes

No

Please note any relevant information or other dental issues not listed above that should be brought to our attention

Approximate date of last general dental check and clean

Are there any siblings who have had or are currently undergoing orthodontic treatment?

Yes

No

If yes, please describe

What are your main concerns about your child’s teeth?

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Find Us

Cannington
Margaret River

address Suites 3 & 4/7-9 Pattie Street,
Cannington
WA 6107, Australia

info@carouselorthodontics.com.au

Opening Hours

Monday:: 8:30am - 5:00pm
Tuesday:: 8:30am - 5:00pm
Wednesday:: 8:30am - 5:00pm
Thursday:: 8:30am - 5:00pm
Friday:: 9:00am - 3:30pm
Saturday:: Closed
Sunday:: Closed

address Suites 12 & 13, The Reef Centre,
33 Fearn Avenue, Margaret River
WA, 6285,

margriverortho@carouselorthodontics.com.au

Opening Hours

Monday:: 9:00am - 5:00pm
Tuesday:: 9:00am - 5:00pm
Wednesday:: 9:00am - 5:00pm
Thursday:: 9:00am - 5:00pm
Friday:: 9:00am - 1:00pm
Saturday:: Closed
Sunday:: Closed

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