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Orthodontic Patient Information FormClick to ... - Dr. Lois James

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Orthodontic Patient Information FormClick to ... - Dr. Lois James Powered By Docstoc
					                                                               Lois James D.D.S.
                                                            17 N. Atlantic Ave., Ste. 4
                                                             Ocean View, DE 19970
                                                                  302-537-4500

                                                 Orthodontic Patient Information Form
Patient Information:

Name: _______________________________________________________________________________
         First                                        Middle                            Last
Nickname: __________________________________                            DOB: ________________ Sex: Female                       Male

Address: ______________________________________________________________________________

Home Phone: ________________________________ Cell Phone: _______________________________

E-Mail: _______________________________________________________________________________

School: _____________________________________________________ Grade: ___________________

Mother’s Name: _______________________________________________________                                       M,     D,     S,    W

Address: ______________________________________________________________________________

DOB: ________________ SSN: _____________________ Occupation:___________________________

Employer: _____________________________ Address: _______________________________________

Home Phone: __________________ Work Phone: _________________ Cell Phone: ________________

Father’s Name: ________________________________________________________                                       M,     D,    S,    W

Address: ______________________________________________________________________________

DOB: ________________ SSN: ____________________ Occupation:____________________________

Employer: __________________________ Address: __________________________________________

Home Phone: __________________ Work Phone: _________________ Cell Phone: ________________

Names and ages of other children in your family _______________________________________________

Who is your family dentist? ___________________________________ Phone: _____________________

   Federal law requires that the parent or guardian who brings the child to appointments is responsible for any incurred fees.
   I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.
   I certify this information is true and correct to the best of my knowledge.
   I will notify you of any changes in my child’s health status or the above information.



Signature: ____________________________________________ Date: _____________
Dental Health:

Why did you come to the dentist today? _____________________________________________________
How long has it been since your last dental exam? _____________________________________________
When were x-rays of your teeth last taken? ______________ Where: ______________________________
Have there been injuries to your face, mouth and/or teeth?……………………………................ YES     NO
Please give dates and descriptions: _________________________________________________________
_____________________________________________________________________________________

Do you have any of the following:

          Snoring………………………………............................................................................... YES NO
          Daytime mouth breathing………………………………................................................... YES NO
          Nighttime mouth breathing………………………………................................................. YES NO
          Tooth grinding……………………………….................................................................... YES NO
          Hearing deficiency……………………………….............................................................. YES NO
          Frequent sinus and/or respiratory infections………………………………....................... YES NO
          Environmental allergies………………………………...................................................... YES NO
                   Taking medications? _____________________________________________
          History of sleep apnea………………………………........................................................ YES          NO
          Speech problems………………………………................................................................. YES NO
          Bleeding gums……………………………….................................................................... YES NO
          Sensitive teeth………………………………..................................................................... YES NO
          Frequent blisters or cold sores………………………………............................................ YES NO
          Root canal treatment………………………………........................................................... YES NO
          Periodontal treatment……………………………….......................................................... YES NO

Are you aware of any missing or extra permanent teeth?……………………………...................... YES                           NO
Are there any unusual sounds (clicking) in the ear during eating?……………………………........ YES                              NO
Have you ever had an orthodontic examination or treatment?…………………………….............. YES                               NO

Are you nervous or frightened during dental visits< If yes, please circle
        Least Nervous 0 1 2 3 4 5 6 7 8 9 10 Most Nervous
Have you had any unfavorable medical or dental experience?……………………………............. YES NO
        Please explain:__________________________________________________________________


Medical Health:

Name of Family Physician: _______________________________ Phone: __________________________
Date of last physical exam: ______________________________
Are you in good health?…………………………….........................................................................YES NO
Have you been under the care of a physician in the last two years? ………………………………..YES NO
         If so, what is the condition being treated? _____________________________________________
Have you had any serious illness or injury?…………………………….......................................... YES NO
         If so, please explain_____________________________________________ Date_____________
Have you ever received a blood transfusion?……………………………........................................ YES NO
         If so, in what years? ______________________________________________________________
Have you ever been hospitalized or had surgery?……………………………................................. YES NO
         Date:____________ Reason: ______________________________________________________
         Date:____________ Reason:_______________________________________________________
         Date:____________ Reason:_______________________________________________________
Women: Are you pregnant?…………………………….................................................................. YES NO
                   If so what month is your baby due? _______________________
         Are you taking oral contraceptives?……………………………........................................ YES NO
                                    Do you have or have you had any of the following? Circle any
           These questions are important for your welfare. If your immune system is depressed, the necessary antibiotic therapy must be more
stringent than if your immune system is healthy. Please help us to provide you with the best dental care possible. If you have any questions, please
ask us.
Have you had abnormal bleeding from previous extractions, surgery and/or trauma?…………… YES NO
Have you been tested for sickle cell anemia?……………………………....................................... YES NO
        If yes, what was the result? ________________________________________________________
Do you take any drug or medication?……………………………................................................... YES NO
        If so, what & how often? __________________________________________________________
Do you take any vitamins or supplements?……………………………........................................... YES NO
        If so, what & how often? __________________________________________________________
Have you ever had an allergic reaction to any of the following: Please circle
          Aspirin or ibuprofen                                 Codeine
          Penicillin or other antibiotics                      Sulfa drugs
          Novocaine, Xylocaine or                              Foods
          other local anesthetics                              Latex
Please describe reaction:__________________________________________________________________
Do you use any complementary or alternative medicine?…………………………….................... YES NO
          Please list: _____________________________________________________________________
Do you smoke?……………………………...................................................................................... YES NO
Do you use any tobacco products, including smokeless, snuff, pates, etc.?……………………….. YES NO
Do you have any disease, condition or problem not listed above that you think we should know about?
Please list: ____________________________________________________________________________

Consent:
1. The Undersigned hereby authorizes the taking of x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the
doctors to make a thorough diagnosis of the patients dental needs.
2. I also authorize the doctors to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy
indicated for such treatment.
3. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that the doctors choose and employ such
assistance as deemed fit to provide recommended treatment.

______________________________________________________                                  _____________________
Signature of Patient or Parent.Guardian if under 18                                     Date

______________________________________________________                                  _____________________
Witness                                                                                 Date

Summary/Notes:______________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________

				
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posted:4/18/2013
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