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
ANY HISTORY OF:
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:
MEDICAL HISTORY
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
DENTAL HISTORY
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
PATIENT MEDICAL/DENTAL HISTORY
In case of emergency, contact:
NAME
PHONE
PURPOSE OF CONSENT (HIPAA)
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. Where appropriate, a credit report may be obtained.
SIGNATURE OF PATIENT
DATE
DOCTOR SIGNATURE
DATE
or
If printing form, please remember to bring completed form with you to your first visit.