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Cannington

(08) 9258 8440

Margaret River

(08) 9758 8150

REFER TO US

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)

Name: Carousel Orthodontics
Telephone: (08) 9258 8440

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 gender identification

Preferred Pronoun

She

They

Other

If other, please give preferred Pronoun 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

*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

If yes, please describe

Currently under the care of any specialist medical practitioners?

Yes

If yes, what for?

Currently taking any regular medications?

Yes

If yes, please list

Allergic to anything?

Yes

If yes, please list

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

Yes

If yes, please describe

Had their tonsils and/or adenoids removed?

Yes

If yes, when

Does your child have any of the following health issues?

ADD/ADHD

Yes

Diabetes

Yes

Asthma

Yes

Epilepsy

Yes

Autism/Aspergers

Yes

Heart or Blood Pressure Problems

Yes

Blood/Bleeding Disorders

Yes

Hepatitis B/HIV

Yes

Cleft Lip or Palate

Yes

Juvenile Arthritis

Yes

Congential Birth Defects/Syndromes

Yes

Kidney or Liver problems

Yes

Depression or other psychological problems

Yes

Speech, learning or hearing problems

Yes

Is there any relevant information or other medical conditions not listed above that should be brought to our attention?

Yes

If yes, please describe

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

Chronic Mouth breathing

Yes

Jaw Joint (TMJ) clicking or locking

Yes

Clenching or Grinding of Teeth

Yes

Persistent Thumb or Finger Sucking

Yes

Dental or Facial Trauma

Yes

Previous Orthodontic Treatment

Yes

Frequent Mouth Ulcers

Yes

Previous Speech Therapy

Yes

Gum Disease

Yes

Tooth Decay, Fillings or Extractions

Yes

Is there any relevant information or other dental issues not listed above that should be brought to our attention?

Yes

If yes, please describe

Approximate date of last general dental check and clean

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

Yes

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

(08) 9258 8440

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

(08) 9758 8150

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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Medical And Dental History (Child/Adolescent Form)

Patient details

Has/Is your child

Does your child have any of the following health issues?

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

Please sign here:

Find Us

Medical And Dental History
(Child/Adolescent Form)