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CONFIDENTIAL PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION
Residential Type

INSURANCE INFORMATION


EMERGENCY CONTACT

HEALTH HISTORY
Have you had a history of any of the following?
ADHD / ADD
Cleft Lip / Palate
Kidney Disease
Allergies
Depression
Learning Disability
Anemia
Diabetes
Liver Disease
Asthma
Dizziness / Fainting
Premature Birth
Autism
Epilepsy
Rheumatic Fever
Behavioral Disorders
GERD / Reflux
Seizures
Bleeding / Transfusion
HIV / AIDS
Snoring / Noisy Breathing While Sleeping
Bleeding Disorders
Heart Disease
Speech / Hearing Problems
Cancer / Tumors
Hepatitis
Cerebral Palsy
Hospitalizations
Is the patient under the care of a physician for a specific condition not listed above?
Is the patient taking any medications?
Is the patient up-to-date on their required immunizations?
Has the patient ever been hospitalized or had treatment under general anesthesia?
Has the patient ever had a visit to the emergency room?
Do you consider the patient to be
Has the patient ever received serious trauma or injury to the teeth, face, jaws or head?
Has the patient ever experienced an adverse reaction during a medical or dental procedure?
Does the patient have pain with chewing, yawning, or wide opening?
Does the patient’s jaw make noise and is pain associated with the sounds?
Does the patient grind their teeth?
Does the patient have any speech problems/tongue thrust?
Does the patient have, or ever had, any pacifier, thumb or finger sucking habits?
Does the patient have a family history of jaw size imbalance or missing, impacted, malformed or extra teeth?
Has the patient been treated for or diagnosed with any periodontal problems?

FLOURIDE HISTORY
Is your drinking water fluoridated?
Do you use well water in your home?
If yes, has it been analyzed for flouride?
Does the patient use a flouride toothpaste?
Does the patient use any other form of fluroide?

ORTHODONTIC HISTORY
For Patients Age 7 & Older
Has the patient had any previous orthodontic treatment or consultation?
Please best describe the patient's attitude toward orthodontic treatment

GROWTH & DEVELOPMENT DATA
Girls: Has the patient's menstruation started?
Boys: Has the patient’s voice changed?
Is the patient still actively growing?

AUTHORIZATION
I agree that I have received and reviewed the Financial Responsibility Form
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the orthodontist and pediatric dentist to help determine appropriate and helpful treatment. I also understand that if there is any change to my, or the above named patient’s dental or medical status, it is my responsibility to inform the doctor.