Child New Patient Information

drmattgaworski.com - Child Registration Form

Child Patient Information

Gender:

Responsibile Party Information

Parent 1

Marital Status
How would you prefer to be contacted for appointment reminders:

Parent 2

Marital Status
How would you prefer to be contacted for appointment reminders:

Dental Insurance Information

Dental History

Do you feel that your teeth are too small or short?
Do you feel that your teeth are too large or long?
Do you feel that your teeth are misshapen?
Do you feel that your teeth are too crooked or crowded?
Do you feel there is too much or too little gum tissue showing when you smile?
Have you ever had any pain, tenderness, or stiffness in your jaw joint (TMJ/TMD)?
Do you have any speech problems?
Have you ever had any injury to face, mouth, teeth or chin?

Airway History

Have you ever worn a CPAP for apnea issues?
Are you a restless sleeper?
Do you snore at night?
Do you sleep walk?
Are you a mouth breather?
Any isssues with bed wetting?
Do you clench/grind your teeth?
Do you sleep talk?
Have you ever worn an Oral Appliance for sleeping, snoring or apnea?
Do you have a problem concentrating either at home, school or work?
Have your tonsils and/or adenoids been removed?
Which?

Habits

Sucking your thumb or fingers?
Lip sucking or biting?
Thrusting your tongue when swallowing?
Other oral/mouth habits?

Medical History

Have you ever had any of the following medical problems listed below:
Do you require premedication prior to dental visits?
Have you ever taken bisphosphonate drugs use to treat osteoporosis or multiple myeloma?
Have you ever taken medications to strengthen your bones and prevent fractures?
Has puberty begun?
Has menstruation (period) begun?
Are you pregnant?
Do you have any allergies to the following?

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in strict confidence and it is my responsibility to inform this office of any changes to medical status.

I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and authorize payment of any insurance benefits.



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  • Dr. Matt Gaworski Orthodontics - 6140 Tutt Blvd., Suite 250, Colorado Springs, CO 80923 Phone: 719-596-2477

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