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