Patient Information Form Page 2

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D
H
ENTAL
ISTORY
General Dentist ________________________________
Last Visit _____________________
How did you hear about our Practice?
 Ad  Internet
 Family or Friend
 Physician
 Other
Name of person referring (if applicable) ____________________________________________
What are the main concerns you would like orthodontics to accomplish?
____________________________________________________________________________
Have you visited an orthodontist before?  Y  N
When? ____________________
Reason? ________________________________________
Have your tonsils or adenoids been removed?  Y  N
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD) ?  Y  N
Do you have any missing or extra permanent teeth?  Y  N
Have you ever had an injury to (select all that apply):  Teeth
 Mouth
 Chin
Do you have speech problems?  Y  N
If so, explain _____________________
Do your gums bleed?  Y  N
Do you smoke?  Y  N
Do you like your smile?  Y  N
Do you currently or have you ever had any of the following habits
(check all that apply)
Clenching/Grinding Teeth
Mouth Breathing
Thumb / Finger Sucking
Lip Sucking/Biting
Nail biting
Chewing / Eating Problem
M
H
EDICAL
ISTORY
Are you currently being treated by a physician?  Y  N Reason ______________________
Physician ________________________
Last Visit ______________ Phone ____________
Do you have any allergies/sensitivities to medications or latex?  Y  N
If yes, please list allergies.
____________________________________________________________________________
Are you currently taking any prescription or over-the-counter medications?  Y  N
Please list, with dosage. _______________________________________________________
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These
include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin
 Y
 N
(fenfluramine) and Redux (dexfenfluramine)?
Have you had any serious illnesses or operations? If yes, describe:
____________________________________________________________________________
 Y
 N
Have you ever had a blood transfusion?
If yes, give approximate dates: _____________________________________________
(Women)
 Y
 N
Nursing?  Y  N
Taking birth control pills?  Y  N
Are you pregnant?

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