<p> Welcome to North Shore Orthodontics! We would like to welcome you and your child to our office. Our goal is to make your visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.</p><p>Dr. Gregory D. Gough, D.D.S www.northshore-ortho.com [email protected]</p><p>Child/Teen Health Questionnaire Person Responsible for Account Tell Us About Your Child Please fill out information below</p><p>Child’s Name: ______Male __ Female __</p><p>Birth Date: ___/___/___ Nickname: ______</p><p>Address: ______City: ______</p><p>State: _____ Zip Code: ______</p><p>Home Phone Number: ______</p><p>School: ______</p><p>Hobbies: ______</p><p>______</p><p>Dental Care General Dentist: ______</p><p>Last Visit Date: ______</p><p>Whom may we thank for referring you? ______Please List a Neighbor or Relative Not Living With You Name: ______Phone Number: ______Address: ______City: ______State: ______Zip Code: _____ Name:______D.O.B: ____/____/_____ Work Phone Number: ______Home Phone Number: ______Employer: ______</p><p>Name:______D.O.B: ____/____/_____ Work Phone Number: ______Home Phone Number: ______Employer: ______</p><p>Orthodontic Coverage? ___yes ___no Insurance Company Name and Address: ______Insurance Co. Phone #: ______Group #: ______Policy Owner’s Employer: ______Policy Owner’s Name: ______D.O.B: ___/___/____ Social Security Number: ______Relationship To Patient: ______</p><p>Orthodontic Coverage? ___yes ___no Insurance Company Name and Address: ______Insurance Co. Phone #: ______Group #: ______Policy Owner’s Employer: ______Policy Owner’s Name: ______D.O.B: ___/___/____ Social Security Number: ______Relationship To Patient: ______Child/ Teen Health Questionnaire Continued… Has your child ever  What are the main had any of the concerns that you following medical would like addressed? ______problems? Please ______circle.  Has your child ever been Y N -Abnormal Bleeding evaluated for or had Y N -ALLERGIES TO LATEX orthodontic treatment Y N -Disabilities before? Yes__ No__ Y N -ALLERGIES TO  Have there been any DRUGS injuries to the face, Y N -Any Hospital Stays mouth, teeth, or chin? Y N -ALLERGIES TO Yes __ No__ If yes, PLASTIC please explain: Y N -Any Operations ______Y N -Asthma ______Y N -Cancer ______Y N -Congenital Heart ______Defect Y N -Convulsions/Epilepsy  List any musical Y N -Hearing Impairment instruments Y N -Heart Murmur played:______Y N -Hemophilia ___ Y N -Hepatitis ______Y N -HIV/AIDS ______Y N -Kidney/Liver ______Problems  Have adenoids or tonsils Y N -Rheumatic/Scarlet been removed? Yes__ Fever No__ Y N -Tuberculosis(TB)  Has your child been Y N -Diabetes informed of any missing Please list EVERYTHING or extra permanent that your child is allergic teeth? Yes__ No__ to, and discuss any  Has your child ever had medical problems that any pain/tenderness in your child has had: his/her jaw joint? ______(TMJ/TMD) Yes__ No______ Does your child brush ___ his/her teeth daily? ______Yes__ No______ Does your child floss ___ his/her teeth daily? ______Yes__ No______Does/did your child have any of the following habits? Y N -Clenching/Grinding Y N -Nursing Bottle Habits Y N -Lip Sucking/Biting Y N -Speech Problems Y N -Mouth Breather Y N -Thumb/Finger Sucking Y N -Nail Biting Y N -Tongue Thrust Is your child currently under the care of a physician? Yes__ No__ Child’s Physician: ______Phone Number: ______Date of last visit:______Has puberty begun? Yes__No__ Please describe your child’s current physical heath: Good___ Fair___ Poor___</p>