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?
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21. Do your gums bleed?
YES
NO
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22. Have you ever had gum disease, or periodontal treatment?
YES
NO
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23. Do you frequently get sore spots in your mouth?
YES
NO
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24. Do you have any dental complaints at the present time?
YES
NO
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25. Do you experience frequent headaches?
YES
NO
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26. Do you have a history of back or neck injuries? Whiplash?
YES
NO
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27. Do you have any clicking or popping of your jaw (TMJ)?
YES
NO
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28. Do you have pain in or around your ears?
YES
NO
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29. Does any part of your mouth hurt when clenched?
YES
NO
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30. Do you habitually clench or grind your teeth during the night or day?
YES
NO
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31. Do you chew on only one side of your mouth?
YES
NO
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If so, why? |
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32. Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc )?
YES
NO
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If so, where? |
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33. Have you ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?
YES
NO
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34. Have you ever taken medication for treatment of Osteoporosis?
YES
NO
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PATIENT MEDICAL/DENTAL HISTORY |
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In case of emergency, contact: |
NAME |
PHONE |
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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. |
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SIGNATURE OF PATIENT |
DATE |
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DOCTOR SIGNATURE |
DATE |
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