New Patient Form (Copy) — Georgetown Family Orthodontics

Heart *

None Heart Murmur Congenital Heart Defect Low/High Blood Pressure

Kidney *

None Bladder Urinary Problems

Liver/GI *

None Stomach/Intestinal Ulcers Gastritis Colitis Hepatitis Liver Disease

Endocrine System *

None Diabetes Thyroid Disease

Lung/Breathing *

None Hay Fever Sinus Trouble Allergies or Hives Asthma Chronic Cough Emphysema TB or Tuberculosis

Neurological *

Hearing/Eye *

None Vision Problems Glaucoma Eye Pain Earaches Hearing Loss

Dermal/Musculoskeletal *

None Rash Allergy to Latex Arthritis Fever Blisters Ulcers

Sleep Related Breathing Problems *

None Snoring Restless Sleeper Falling Asleep at School Frequently Tired Trouble Concentrating at School Morning Headaches

Does the patient have any disease, condition, syndrome or other health problem not listed above? *

Yes No

Is the patient in good health? *

Yes No

Is he/she up to date with immunizations? *

Yes No

Has he/she been hospitalized since birth? *

Yes No

Is the patient currently taking any medications? *

Yes No

Is the patient allergic to any medications or drugs? *

Yes No

Is he/she presently receiving medical treatment? *

Yes No

When was the child’s last physical exam? *

Describe your child's personality and interaction with the parent/guardian:

New Patient Form