| 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 the patient's hobbies? | |||
| 7. In your own words describe the patient's 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. Is the patient in general good health at this time? YES NO | |||
| 2. Is the patient under any medical treatment now? YES NO | |||
| 3. Is the patient taking any drugs or medications? YES NO | |||
| 4. Has the patient ever had any adverse response to any drugs, including penicillin? YES NO | |||
| 5. Is the patient allergic to any known materials resulting in hives, asthma, eczema, etc.? YES NO | |||
| 6. Is the patient allergic to latex? YES NO | |||
| 7. Has the patient ever had any major operations including hip/joint replacement? YES NO | |||
| If YES please specify: | |||
| 8. Does the patient have any wounds that healed slowly or presented other complications? YES NO | |||
| 9. Has the patient had any radiation therapy or chemotherapy? YES NO | |||
| 10. Has the patient had a serious accident involving head injuries? YES NO | |||
| 11. Has the patient 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. Does the patient snore? YES NO | |||
| 13. Does the patient have unexplained awakenings from sleep? YES NO | |||
| 14. Does the patient stop breathing for short periods during sleep? YES NO | |||
| 15. Does the patient get excessively tired during the day and/or fall asleep when they should be awake? YES NO | |||
| 16. Is the patient on a diet at this time? YES NO | |||
| 17. Does the patient have a history of fainting? YES NO | |||
| 18. Is the patient pregnant? YES NO | |||
| 19. Has the patient ever smoked or used Tobacco products? YES NO | |||
| 20. FEMALES: Started Menstruation? YES NO | |||
| If so, how long ago? | |||
| The following information is requested to enable us to give the patient the best consideration of their 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 the patient's last full-mouth x-rays taken? Where? | |||
| 22. Do the patient's gums bleed? YES NO | |||
| 23. Has the patient ever had gum disease, or periodontal treatment? YES NO | |||
| 24. Does the patient frequently get sore spots in their mouth? YES NO | |||
| 25. Does the patient have any dental complaints at the present time? YES NO | |||
| 26. Does the patient experience frequent headaches? YES NO | |||
| 27. Does the patient have a history of back or neck injuries? Whiplash? YES NO | |||
| 28. Does the patient have any clicking or popping of their jaw (TMJ)? YES NO | |||
| 29. Does the patient have pain in or around their ears? YES NO | |||
| 30. Does any part of the patient's mouth hurt when clenched? YES NO | |||
| 31. Does the patient habitually clench or grind their teeth during the night or day? YES NO | |||
| 32. Does the patient chew on only one side of their mouth? YES NO | |||
| If so, why? | |||
| 33. Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc )? YES NO | |||
| If so, where? | |||
| 34. Has the patient ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)? YES NO | |||
| 35. Has the patient 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 PARENT/GUARDIAN | DATE | ||
| DOCTOR SIGNATURE | DATE | ||
| or |