We look forward to welcoming you and your child to First Smiles.
We kindly request that you please provide the following information in advance of your initial consultation with your Orthodontist. A thorough and complete medical and dental history is very important for an orthodontic consultation. Your responses will be kept confidential in accordance with our Privacy Policy
Title*: —Please choose an option—MasterMissOther
Date of Birth*:
Gender*: —Please choose an option—FemaleMaleNon-Binary
State*: —Please choose an option—WANSWVICQLDSANTTAS
Does your child play a musical instrument? YesNo
Parent/Guardian 1
Relation to Patient*: —Please choose an option—MotherFatherStepmotherStepfatherPartnerGrandparentGodparentAuntUncleGuardianOther
Title*: —Please choose an option—MrsMrMsDrDeceasedOther
Please complete the contact information below if different to the Patient details. If Parent/Guardian contact details are the same as the Patient contact details, please leave blank.
State: —Please choose an option—WANSWVICQLDSANTTAS
Parent/Guardian 2
Relation to Patient: —Please choose an option—MotherFatherStepmotherStepfatherPartnerGrandparentGodparentAuntUncleGuardianOther
Title: —Please choose an option—MrsMrMsDrDeceasedOther
Who will be the Billing Party for the Patient’s account?*: Parent/Guardian 1Parent/Guardian 2Other Person
Please complete the contact information below if the Billing Party is NOT the Parent/Guardian1 or Parent/Guardian2:
Who does the Patient live with? (select all that apply) MotherFatherStepmotherStepfatherPartnerGrandparentGodparentAuntUncleGuardianOther
Who will be bringing the Patient to appointments? (select all that apply) MotherFatherStepmotherStepfatherPartnerGrandparentGodparentAuntUncleGuardianBabysitterNannyAu pairOther
Does the Patient have any siblings? YesNo
Sibling 1 First Name:
Sibling 1 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Current patient of First Smiles? YesNo
Sibling 2 First Name:
Sibling 2 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Sibling 3 First Name:
Sibling 3 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Sibling 4 First Name:
Sibling 4 Age: —Please choose an option—<6 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years>18 years
Referred by General Dentist
Referred by another Practitioner
A family member comes here
A friend comes here
Google Search/Website
Facebook
Instagram
Drove / walked past the practice
Recommended by someone else
Does your child see a Dental Practitioner for their regular dental care?* YesNo
Has your child ever seen a Specialist Paediatric Dentist?* YesNo
Has your child ever seen any other Specialist Dentists (eg. Prosthodontists, Oral & Maxillofacial Surgeons, Periodontists)?* YesNo
Does your child see a General Practitioner (GP or Doctor) for their regular medical care?* YesNo
Is your child seeing any other Medical Specialists? YesNo
Has your child had orthodontic treatment previously?* YesNo
Are you seeking a second opinion for your child’s orthodontic treatment plan?* YesNo
There are some orthodontic conditions that are more genetically prevalent in families (eg. missing teeth, narrow upper jaws, underbites) and so it is very helpful to be provided with the orthodontic history of your child’s immediate and extended family.
Have any of your child’s siblings (brothers/sisters) had orthodontic treatment?* YesNo
Have any of your child’s parents had orthodontic treatment?* YesNo
Have any of your child’s extended family members (aunts/uncles/cousins/grandparents) had orthodontic treatment?* YesNo
Has your child ever had (now or in the past) the following medical conditions?* YesNo
If yes, please tick all that apply:
Premature birthDifficult birthTwinBehavioural problemsADD or ADHDAutism spectrum disorderOther developmental disorderSensory sensitivitiesCommunication difficultiesSpeech therapyIntellectual disabilityPhysical disabilityTraumatic medical experienceEating disorder eg. anorexia or bulimiaAnxietyDepressionOther mental health disturbancesFrequent headaches or migrainesSeizuresEpilepsy (fits)Fainting spellsMultiple sclerosisCerebral palsyNervous system disorderOther neurological issuesChest pain or shortness of breathTire easilyHigh or low blood pressureRheumatic feverCongenital heart defectHeart murmurRheumatic heart diseaseAnginaArteriosclerosisStrokeHeart attackCardiac pacemakerHeart valve replacementAny other heart (cardiac) issueAsthmaBronchitisPneumoniaCystic fibrosisRespiratory diseaseOther lung conditionsCancer or a tumorChemotherapy or radiation therapyTransplanted organBone marrow or stem cell transplantInjuries to the face, head or neckBone fractureJoint replacement surgeryArthritisLow bone densityOsteoporosisVision issue (including wearing glasses)Eye surgeryDeaf or hearing issueRecurrent ear infectionsTonsil or adenoid conditionHayfeverSinus problemsDiabetes or low blood sugarEndocrine or thyroid problemsThyroid problems (including goiter)Gastroesophageal reflux disease (GORD)Inflammatory bowel diseaseFamily history of diabetesUrinary tract infectionsKidney diseaseImmunocompromisedAutoimmune diseaseEczemaSkin disorders (other than common acne)Extensive burnsExcessive bleedingExcessive bruisingAnaemiaBlood disorderHepatitisJaundice or liver diseaseTuberculosisPolioMononucleosisGonorrhoea, syphilis, herpes or other sexually transmitted diseasesAIDS or HIVOther infectious disease
Sleep & Breathing
Does your child snore?* YesNo
Has your child had their tonsils and/or adenoids removed?* YesNo
Has your child been diagnosed with, or could they have, sleep apnea?* YesNo
Medications/Lifestyle
Some medicines may interfere with your child’s orthodontic treatment. It is important that we know precisely what medications (if any) which your child is taking.
Does your child take, or has been taking recently, any of the following medications?* YesNo
AspirinWarfarin or Heparin (or other blood thinners)Oral contraceptive (the Pill)Cortisone or steroidsMedication for depression or anxietyTreatment for osteoporosis (Bisphosphates, Prolia)Hormone supplementsFluoride supplementsOther prescription medicationsHerbal or naturopathic medicationsNutritional supplementsOver-the-counter medications
If you have ticked any of the medications above, please provide dose and frequency
Could your child have a substance abuse problem (alcohol, drugs)?* YesNo
Could your child smoke cigarettes (including vaping and e-cigarettes)?* YesNo
Family History
Does your child have any birth defects or hereditary problems?* YesNo
Does your child’s siblings and/or parents have any of the following health problems?* YesNo
Bleeding disordersDiabetesArthritisSevere allergiesMissing teethExtra teethJaw size imbalanceProminent lower jaw (underbite)Recessive lower jawUnusual dental problems
Does your child have any other medical conditions that we should be aware of?* YesNo
Is your child allergic to, or has had an allergic reaction, to any of the following?* YesNo
Local anaesthetics eg. novocaine, lidocaine, xylocaineIbuprofen eg. Nurofen, AdvilAspirinPenicillinOther antibioticsMetals eg. jewellery, clothing snapsLatex eg. gloves, balloonsAcrylicsAnimalsFoodsPlant pollensOther allergies
Now or in the past, has your child had any of the following?* YesNo
Teeth erupting earlyTeeth erupting latePrimary (baby) teeth removed that were not loose or ready to fall out naturallyPermanent teeth removedExtra (supernumerary) teeth removedLost or broken fillingsDental injury or dental traumaTeeth causing irritation to the lips, cheeks or gumsTeeth treated with root canals or pulpotomiesCysts in the mouth/jaw regionJaw fracturesTraumatic dental experienceFrequent canker sores or cold soresSensitive or sore teethSoreness in jaw muscles or facial musclesTooth grinding or clenchingTMJ or TMD problemsClick or locking jaw jointsPacifier (dummy) useFinger suckingThumb suckingPen chewingOral sensitivities
How often does your child brush their teeth?* —Please choose an option—Twice DailyDailyWeeklyOccasionallyUnsure
Does your child wear a mouthguard when playing sport?* YesNoNot Required
Do you think any of your child’s activities affect their face, teeth or jaws? YesNo
Have you noticed any unusual changes in your child’s face or jaws? YesNo
Does your child have any other dental history we should be aware of? YesNo
By electronically clicking SUBMIT on this Medical History Questionnaire, I hereby certify:
I have read all of the questions in the Medical History Questionnaire online at www.smilewithconfidence.com.au/firstsmiles-mhqu18/ and will not hold the Orthodontist nor First Smiles responsible for any errors or omissions which I have made in the completion of this Medical History Questionnaire.
I confirm that, to the best of my knowledge, the information provided in this Medical History Questionnaire is true and accurate and reflects all that is relevant in the treatment of my child for orthodontics.
I will notify First Smiles of any changes in my child’s medical or dental health as soon as reasonably practicable.
I consent to the performance of a comprehensive clinical examination and assessment of my child for orthodontic treatment including the procurement of diagnostic records such as digital photographs, digital radiographs and digital study model scans.
I consent to the sharing and release of my child’s personal and dental records to other dental and medical practitioners involved in my child’s care.
I consent to the use and publication of my child’s dental records (including photographs, radiographs and videos) made in the course of examinations, treatment and review for purposes of professional consultations, research, education, publication in professional journals and for marketing purposes including social media.
I DO NOT consent to the use and publication of my child’s dental records (including photographs, radiographs and videos) made in the course of examinations, treatment and review for purposes of professional consultations, research, education, publication in professional journals and for marketing purposes including social media.
Please tick this box if you do not consent to your child’s orthodontic records being used for this purpose.
I am aware First Smiles has a Privacy Policy which is located at www.firstsmiles.com.au/privacy-policy/. I understand the reasons why our personal information must be collected and hereby consent to the handling of our personal information by First Smiles or the Orthodontist in accordance with this Privacy Policy.
I understand payment for fees for consultations and diagnostics records will be required on the day of the appointment. Non-payment of your account may be sent to debt-collector with the costs associated with debt recovery charged to your account. Payment of fees for orthodontic treatment will be subject to a separate financial agreement.
I understand and agree that by clicking SUBMIT online, I have electronically signed this Medical History Questionnaire.