• Orthodontic Registrations

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  • Format: (000) 000-0000.
  • SEX*
  • FULL TIME STUDENT*
  • NEAREST RELATIVE OR FRIEND'S NAME, ADDRESS & PHONE (not at same address)*

  • Person Responsible for This Accout

  •  / /
  • Format: (000) 000-0000.
  • MARITAL STATUS*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • HOW LONG EMPLOYED*
  • Format: (000) 000-0000.
  •  / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • MARITAL STATUS
  • Format: (000) 000-0000.
  • HOW LONG EMPLOYED
  • Format: (000) 000-0000.

  • HEALTH HISTORY

  • I. Circle Appropriate Header

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  • Is your general health good?*
  • Has there been a change in your health within the last year?*
  • Have you been hospitalized or had a serious illness in the last three years?*
  • Are you being treated by a physician now? For what?*
  • Have you had problems with prior dental treatment?*
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  • Any prior orthodontic treatment (retainers, braces, expander, etc.)*

  • II. DO YOU HAVE OR HAVE YOU HAD: (If yes, please indicate by circling appropriate answer)

  • Heart Problems? If so, what?*
  • Rheumatic fever?*
  • Stroke, hardening of arteries?*
  • High blood pressure?*
  • Asthma, TB, emphysema, other lung disease?*
  • Hepatitis, other liver disease?*
  • Family history of diabetes, heart problems?*
  • Psychiatric care?*
  • Radiation treatments?*
  • Chemotherapy?*
  • Artificial joint?*
  • Tumors, cancer?*
  • Arthritis, rheumatism?*
  • Jaw popping, clicking, or difficulty opening*
  • Snoring?*
  • Frequent Sore Throat?*
  • Allergies: food, medication, latex, nickel?*
  • Anemia?*
  • VD (syphilis/gonorrhea)?*
  • Herpes?*
  • Kidney, bladder disease?*
  • Thyroid, adrenal disease?*
  • Diabetes?*
  • HIV/AIDS?*
  • Hospitalization?*
  • Blood transfusions?*
  • Osteoporosis?*
  • Pacemaker?*
  • Surgeries?*
  • Headaches?*
  • Sleep with mouth open?*
  • Tonsils/Adenoids Removed?*
  • Seasonal Allergies:*

  • III. ARE YOU TAKING:

  • Recreational drugs?*
  • Drugs, medications, over-the-counter medicines (including aspirin), natural remedies?*
  • Tobacco in any forms?*
  • Alcohol?*

  • IV. WOMEN ONLY

  • Are you or could you be pregnant or nursing?*
  • Taking birth control pills?*

  • V. ALL PATIENTS

  • Do you or have you had any other diseases or medical problems NOT listed on this form?*

  • To the best of my knowledge, 1 have answered every question completely and accurately. / will inform my dentist of any change in my health and/or medication

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  • HEADACHE AND FACIAL PAIN SCREENING QUESTIONNAIRE

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  • Temporomandibular Disorders are a frequent cause of headaches, facial pain and dental pain. Please complete this screening questionnaire.

    SYMPTOM CHECKLIST: Please check any of the following symptoms that apply to you. (L-left and R-right)

  • Headaches?
  • Top of Head
  • Forehead
  • Back of Head
  • Pain in Head
  • Pain in Ear
  • Dizziness (vertigo)
  • Pain in Jaw Joint
  • Temples
  • Behind Eyes
  • Pain in Shoulder
  • Ear Congestion
  • Tinnitus (ringing in ears)
  • Facial Pain (non-specific)
  • Grating sound in joint
  • Clicking or popping in jaw joint
  • Partial inability to open mouth
  • Face muscle twitch
  • Difficulty swallowing
  • Difficulty breathing through nose
  • Diffculty chewing
  • Have you ever worn braces

  • SLEEP APNEA EVALUATION

  • We have seen a recent increase of sleep apnea findings in our patients, which is a life threatening medical problem. To protect your health, we are asking you to complete the following screening form.

    Please answer:

  • Do you snore?
  • Are you excessively tired during the day?
  • Have you been told you stop breathing during sleep?
  • Do you have a history of hypertension?
  • Is your neck size greater than... (17 inches - male | 16 inches female)
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  • Should be Empty: