| NUMBER OF CHILDREN IN THE FAMILY: | |||
| NAME OF ANY FAMILY MEMBER IN TREATMENT OR PREVIOUSLY WITH US: | |||
| NAME OF PREVIOUS ORTHODONTIST: | |||
| GENERAL DENTIST'S NAME | ADDRESS | PHONE | |
| DATE OF LAST DENTAL CHECK-UP | CURRENTLY UNDER TREATMENT? YES NO | ||
| PHYSICIAN'S NAME | ADDRESS | PHONE | |
| DATE OF LAST CHECK-UP | CURRENTLY UNDER TREATMENT? YES NO | ||
| 1. Thumb or finger sucking? YES NO | If YES, Until what age?: | ||
| 2. Grinding of teeth? YES NO | If YES, When?: | ||
| 3. Frequent headaches or jaw pain? YES NO | |||
| 4. Difficulty eating any foods? YES NO | |||
| 5. Speech difficulty or speech therapy? YES NO | |||
| 6. What are your hobbies? | |||
| 7. In your own words describe your main orthodontic problem: | |||
| The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you. | |||
| 1. Are you in general good health at this time? YES NO | |||
| 2. Are you under any medical treatment now? YES NO | |||
| 3. Are you taking any drugs or medications? YES NO | |||
| 4. Have you ever had any adverse response to any drugs, including penicillin? YES NO | |||
| 5. Are you allergic to any known materials resulting in hives, asthma, eczema, etc.? YES NO | |||
| 6. Are you allergic to latex? YES NO | |||
| 7. Have you ever had any major operations including hip/joint replacement? YES NO | |||
| If YES please specify: | |||
| 8. Have any wounds healed slowly or presented other complications? YES NO | |||
| 9. Have you ever had any radiation therapy or chemotherapy? YES NO | |||
| 10. Have you ever had a serious accident involving head injuries? YES NO | |||
| 11. Have you had a history of any of the following? | |||
| ASTHMA | CARDIOVASCULAR DISEASE | CANCER | HAY FEVER |
| HEART MURMUR | HERPES | SINUS PROBLEMS | RHEUMATIC FEVER |
| TUMOR OR GROWTH | RESPIRATORY PROBLEMS | BLOOD DISEASE | SEXUALLY TRANSMITTED DISEASE |
| TONSILLITIS | BONE DISORDER | EMOTIONAL PROBLEMS | DIZZINESS |
| AIDS OR HIV POSITIVE | EXCESSIVE BLEEDING | CONVULSIONS | IMMUNE SYSTEM PROBLEMS |
| FAINTING | EPILEPSY | INFECTIOUS DISEASE | HEPATITIS OR LIVER DISEASE |
| DIABETES | ARTHRITIS OR PAINFUL JOINTS | ALCOHOLISM | HEARING DISORDER |
| MIGRAINE HEADACHES | DRUG ABUSE | OTHER | |
| OTHER Conditions not listed: | |||
| 12. Do you snore? YES NO | |||
| 13. Do you have unexplained awakenings from sleep? YES NO | |||
| 14. Do you, or have you been told that you stop breathing for short periods during sleep? YES NO | |||
| 15. Do you get excessively tired during the day and/or fall asleep when you should be awake? YES NO | |||
| 16. Are you on a diet at this time? YES NO | |||
| 17. Do you have a history of fainting? YES NO | |||
| 18. Are you pregnant? YES NO | |||
| 19. Have you ever smoked or used Tobacco products? YES NO | |||
| The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you. | |||
| 21. When were your last full-mouth x-rays taken? Where? | |||
| 21. Do your gums bleed? YES NO | |||
| 22. Have you ever had gum disease, or periodontal treatment? YES NO | |||
| 23. Do you frequently get sore spots in your mouth? YES NO | |||
| 24. Do you have any dental complaints at the present time? YES NO | |||
| 25. Do you experience frequent headaches? YES NO | |||
| 26. Do you have a history of back or neck injuries? Whiplash? YES NO | |||
| 27. Do you have any clicking or popping of your jaw (TMJ)? YES NO | |||
| 28. Do you have pain in or around your ears? YES NO | |||
| 29. Does any part of your mouth hurt when clenched? YES NO | |||
| 30. Do you habitually clench or grind your teeth during the night or day? YES NO | |||
| 31. Do you chew on only one side of your mouth? YES NO | |||
| If so, why? | |||
| 32. Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc )? YES NO | |||
| If so, where? | |||
| 33. Have you ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)? YES NO | |||
| 34. Have you ever taken medication for treatment of Osteoporosis? YES NO | |||
| In case of emergency, contact: | |||
| NAME | PHONE | ||
By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations. |
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| SIGNATURE OF PATIENT | DATE | ||
| DOCTOR SIGNATURE | DATE | ||
| or |