Bracesfrisco-AdolescentForm

Adolescent Patient Information

Name

Preferred Name

Birthdate

Age

Gender*

Male Female

Address

Home Phone

Cell

School

Grade

Dentist

Date of last visit

Siblings (Name/DOB)

Adopted

Yes No

Whose facial/dental structure does patient resemble?

Father Mother

Has the patient ever had an orthodontic evaluation before?

Yes No

If so, where?

Parent/Guardian Information

*** If parents are separated/divorced, please circle the name of the person who is financially responsible.***

Father

Dr Mr

Name

Address (home)

# of years @ address

Phone (home)

(Work)

(Cell)

Employer

# of years

Occupation

Birthdate

SSN

Mother

Dr Miss Ms. Mrs.

Name

Address (home)

# of years @ address

Phone (home)

(Work)

(Cell)

Employer

# of years

Occupation

Birthdate

SSN

Additional Information

What is your chief concern?

Whom may we thank for referring you to mbrace orthodontics?

Retention of Documents Relating to Patient Care. By signing this, you understand and agree that is it our policy to scan and store original documents in electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed in electronic form, has the same force and effect as the original document.

Name

Signature

Date

Dental History

Check if the patient currently has or has had any of the following:

Blisters on lips/mouth

Broken fillings

Burning sensation, tongue

Chews on tongue

Dry mouth

Extracted teeth

Finger/thumb habits

Food trapped between teeth

Grinding teeth

Gums bleeding

Gums sore/swollen

Injuries to teeth/jaw

Injuries to face/head

Jaw clicking/popping

Jaw locking open/closed

Jaw pain/tenderness

Jaw surgery

Lip/cheek biting

Loose teeth (other than baby teeth)

Mouth breathing

Mouth pain when brushing

Orthodontic treatment

Pain around ear

Periodontal treatment

Periodontal surgery

Sensitivity to hot or cold

Sensitivity to sweets

Sensitivity to pressure

Sores/growths in mouth

Speech problems

Tongue thrust

HOW OFTEN DOES THE PATIENT BRUSH?

FLOSS?

ADDITIONAL COMMENTS

MEDICAL HISTORY

Check if the patient currently has or has had any of the following:

AIDS

Anemia

Arthritis

Artificial heart valves

Artificial joints

Asthma

Back problems

Blood diseases

Bone disorders

Cancer

Chemical dependency

Chemotherapy

Circulatory problems

Cortisone treatment

Coughing - persistent

Diabetes

Epilepsy

Fainting

Glaucoma

Headaches

Heart murmur

Heart problems

Hepatitis

High blood pressure

HIV Positive

Kidney disease

Liver disease

Mitral valve prolapse

Nervous system problems

Pacemaker

Psychiatric Care

Radiation treatment

Respiratory disease

Scarlet fever

Shortness of breath

Stroke

Stomach ulcers

Swelling of feet

Thyroid problems

Tobacco habit

Tonsillitis

Tonsils removed

Tuberculosis

Urinary problems

Other (not listed)

**FEMALES ONLY** AGE OF MANARCHE

IS IT POSSIBLE THE PATIENT IS PREGNANT? Yes No

IS THE PATIENT UNDER THE CARE OF A PHYSICIAN? Yes No

FOR WHAT CONDITION?

PHYSICIAN’S NAME

PHONE

MEDIACATIONS ALLERGIES

Please list ANY & ALL medications the patient is currently taking:

Please list ANY & ALL known allergies you are aware of:

IS THE PATIENT CURRENLY TAKING OR HAS TAKEN ANY BONE DENSITY MEDICATIONS? Yes No

(Aclasta, Actonel, Actonel+Ca, Aredia, Atelvia, Binosta, Bonefos, Boniva, Didronel, Foasmax, Fosamax+D, Reclast, Skelid, or Zometa)

The above information is accurate and complete to the best of my knowledge and is only for use in my child’s treatment. It is my responsibility to inform this office of any changes in my child’s personal information or health status. I will not hold mBrace Orthodontics or the staff responsible for any errors or omissions that I have made in the completion of this form

Name

Signature

Date

Pediatric Sleep Questionnaire

Patient Name:

Date:

Your doctor would like you to complete this form as accurately and honestly as possible. In our practice we are very interested in our patient's overall health. Orthodontic treatment can be an important part of managing the health problems caused by sleep and breating disorders.

Yes No Occasionally

While Sleeping, does your child snore more than half the time?

Yes No Occasionally

While Sleeping, does your child always snore?

Yes No Occasionally

While Sleeping, does your child snore loudly?

Yes No Occasionally

While Sleeping, does your child have "heavy" or loud breathing?

Yes No Occasionally

While Sleeping, does your child have trouble breathing, or struggle to breath?

Yes No Occasionally

Have you ever seen your child stop breathing during the night?

Yes No Occasionally

Does your child occasionally wet the bed, sleepwalk, or have night terrors (circle any)?

Yes No Occasionally

Does your child tend to breathe through the mouth during the day?

Yes No Occasionally

Does your child have a dry mouth on waking up in the morning?

Yes No Occasionally

Does your child wake up unrefreshed in the morning?

Yes No Occasionally

Does your child wake up with headaches in the morning?

Yes No Occasionally

Is it hard to wake your child up in the morning?

Yes No Occasionally

Does your child have a problem with sleepiness during the day?

Yes No Occasionally

Has a teacher or supervisor commented -your child appears sleepy during the day?

Yes No Occasionally

Did your child stop growing at a normal rate at any time since birth?

Yes No Occasionally

Is your child overweight?

Yes No Occasionally

This child often does not seem to listen when spoken to directly.

Yes No Occasionally

This child often has difficulty organizing task and activities.

Yes No Occasionally

This child often is easily distracted by extraneous stimuli.

Yes No Occasionally

This child often fidgets with hands or feet or squirms in seat.

Yes No Occasionally

This child often is 'on the go' or often acts as if 'driven by a motor'.

Yes No Occasionally

This child often interrupts or intrudes on others (butts into conversations or games).

For our practice, Orthodontics is MUCH more than straight teeth.

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dr. Shireen Irani and mBrace Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility and available upon request

Dr. Shireen Irani and mBrace Orthodontics reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices upon request.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

ANY MEMBER OF MY IMMEDIATE FAMILY

Yes No

SPOUSE ONLY

Yes No

OTHER (PLEASE SPECIFY):

Yes No

Name of Patient or Personal Representative

Date

SIGNATURE

Description of Personal Representative's Authority