Patient Information Form

myKIDSdds

Dentistry and Orthodontics for Children

8325 Walnut Hill Lane Suite 111, Dallas, TX 75231 (214-696-3082)

Patient Information

Full

Name

___________________________________________________________

Date

of

Birth

__________________

SS

#________________

Primary Home Address _________________________________________________________________________________Phone # _____________________

Secondary Home Address

______________________________________________________________________Phone # _____________________

(if applicable)

If patient is a minor, parent's or guardians name__________________________________________________________________________________________

Patients hobbies, pets, toys, or pastimes _______________________________________________________________________________________________

Siblings and their ages______________________________________________________________________________________________________________

If patient is an adult, names and ages of children _________________________________________________________________________________________

Whom may we thank for referring you to our office?_______________________________________________________________________________________

If a member of your family is now an orthodontic patient at this office please list their name________________________________________________________

Have you or any member of your family ever been a patient in this office? Please list name:_______________________________________________________

Patient's Dentist, address, and phone #:_____________________________________________________________________Date of last visit:______________

Is this you or your child's first visit to an orthodontist?_____________If not please share with us why you wish to make a change. _________________________

Please discuss your concerns and desires regarding you/or your child's orthodontic care. ________________________________________________________

Does your child have a history of any oral habits? (Mouth breathing, Thumb sucking, Etc.)____________________If so please explain:_____________________

1. Are you (or your child) having jaw pain or discomfort at this time?... ................................................................................................................................ .. YES NO

2. Do you (or your child) feel nervous about having orthodontic treatment?... ....................................................................................................................... ... YES NO

3. Have you (or your child) been admitted to the hospital during the past two years?... ........................................................................................................ .. YES NO

4. Have you (or your child) been under the care of a medical doctor during the past two years?... .......................................................................................... . YES NO

Physician's Name___________________________________________________ Phone # __________________________

5. What medicine or drugs are you (or your child)currently taking or have you taken during the past two years?... ........................................................ .. YES NO

If yes, please list: _____________________________________________________________________________________

6. Are you aware of being allergic to or have you ever reacted adversely to any medication, product, or material?... ...................................................... . YES NO

If yes, please list: _____________________________________________________________________________________

7. Is there any information you can share that will aid us in treating you (or your child)? _________________________________________________________

8. When you walk up stairs or take a walk, do you ever have to stop because of pain in you chest, or shortness of breath, or because you are very tired?

Y

N

9. Do your ankles swell during the day? ... ...................................................................................................................................................................................... Y N

10. Do you use more than 2 pillows to sleep? ... ............................................................................................................................................................................. Y N

11. Have you lost or gained more than 10 pounds in the past year? ... ......................................................................................................................................... .Y N

12. Do you ever wake up from sleep short of breath? ... ................................................................................................................................................................. Y N

13. Are you on a special diet? ......................................................................................................................................................................................................... .Y N