PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE
Date:
Patient's name:
Address:
Nickname:
Birthdate:
Social Security#:
School
Sports/Hobbies
Parent or guardian name
Whom may we thank for referring you to our office?
RESPONSIBLE PARTY INFORMATION
Name
Residence
Mailing Address
How long at this address?
Home phone
Work phone
Cell/other phone
Email address
Previous Address (If less than 3 years)
Social Security #
Birthdate
Relationship to Patient
Employer
Occupation
No. years employed
Spouse's Name
Relationship to Patient
Employer
Occupation
No. years employed
Social Security #
Birthdate
Work Phone
EMERGENCY INFORMATION
Name of nearest relative not living with you
Complete address
Phone
I understand that, where appropriate, credit bureau reports may be obtained.
Parent Signature
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Updates (date & initial)
MEDICAL HISTORY
Physician
Date of Last Visit
Address
Phone
Please circle Yes or No (If Yes, please fill in details)
Yes
No
Is the patient taking any medication?
Yes
No
Is the patient allergic to any medication?
Yes
No
Is the patient allergic to latex?
Yes
No
History of a major illness?
Yes
No
Has the patient had any operations?
Yes
No
Ever been involved in a serious accident?
Yes
No
Have seen a physician in the last 12 months? Why?
Female Patients only:
Yes
No
Has menstruation started?
Yes
No
Is the patient pregnant?
Circle any of the medical conditions below that the patient has had or currently has.
Abnormal bleeding/Hemophilia
Diabetes
Hepatitis/Liver problems
Pneumonia
Anemia
Dizziness
Herpes
Prolonged Bleeding
Arthritis
Epilepsy
High Blood Pressure
Radiation/Chemotherapy
Asthma or Hayfever
Gastrointestinal Disorders
HIV / Aids
Rheumatic Fever
Bone Disorders
Heart Problems
Kidney problems
Tuberculosis
Congenital Heart Defect
Heart Murmur
Nervous Disorders
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
DENTAL HISTORY
General Dentist
Date of last visit
What concerns you most about your teeth?
Yes
No
Are you presently in any dental pain?
Yes
No
Ever experienced any unfavorable reaction to dentistry?
Yes
No
Has the patient ever lost or chipped any teeth?
Yes
No
Have there been any injuries to face, mouth, or teeth?
Yes
No
Is any part of your mouth sensitive to temperature? Where?
Yes
No
Is any part of your mouth sensitive to pressure? Where?
Yes
No
Do gums bleed when brushing?
Yes
No
Any type of thumb or tongue habit?
Yes
No
Do you have any type of thumb or tongue habit?
Yes
No
Has the patient ever seen an orthodontist? If yes, who and when?
Yes
No
What is the patient's attitude toward receiving orthodontic treatment?
Yes
No
Has anyone in the family received orthodontic treatment?
How did they feel about the result?
Yes
No
Do teeth or jaws ever feel uncomfortable first thing in the morning?
Yes
No
Experience jaw clicking or popping?
Yes
No
Aware of clenching or grinding teeth during the day?
Yes
No
Experience "tension" headaches?
Yes
No
Has the patient ever experienced chronic ringing in the ears?
Yes
No
Does the patient need extra help with instructions?
Yes
No
Is the patient sensitive or self-conscious about his/her teeth?
Yes
No
Height of parents? Mom
Dad
Yes
No
Are you aware that some appointments will be during school hours?
BENEFITS
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Adam Cohen, DMD to perform a complete orthodontic evaluation.
Signature
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Date