Orthodontic Registrations

PATIENT'S LAST NAME*

FIRST NAME*

M. INITIAL*

DATE OF BIRTH*

Date

STREET ADDRESS*

CITY, STATE & ZIP*

HOME PHONE*

SEX*

MALEFEMALE

FULL TIME STUDENT*

YESNO

NEAREST RELATIVE OR FRIEND'S NAME, ADDRESS & PHONE (not at same address)*

RELATIVEFRIEND

Dentist*

Address*

PRIMARY BILLING PARTY LAST NAME*

FIRST NAME*

M. INITIAL*

DATE OF BIRTH*

Date

STREET ADDRESS*

CITY, STATE & ZIP*

HOME PHONE*

EMAIL ADDRESS*

example@example.com

DRIVERS LICENSE NO.*

EMPLOYED BY*

MARITAL STATUS*

WORK PHONE*

CELL PHONE*

BUSINESS ADDRESS*

HOW LONG EMPLOYED*

HOURLYSALARYRETIRED

PRIMARY DENTAL INSURANCE CO.*

MAILING ADDRESS*

GROUP #*

SERVICE CODE*

CONTRACT ID*

INS. CO. PHONE NO.*

SECOND BILLING PARTY LAST NAME

FIRST NAME

M. INITIAL

DATE OF BIRTH

Date

STREET ADDRESS

CITY, STATE& ZIP

HOME PHONE

EMAIL ADDRESS

example@example.com

DRIVERS LICENSE NO.

WORK PHONE

EMPLOYED BY

MARITAL STATUS

CELL PHONE

BUSINESS ADDRESS

HOW LONG EMPLOYED

HOURLYSALARYRETIRED

SECONDARY DENTAL INSURANCE CO.

MAILING ADDRESS

GROUP #

SERVICE CODE

CONTRACT ID

INS. CO. PHONE NO.

I. Circle Appropriate Header

Patient Name*

Date of Birth*

Date

Is your general health good?*

YESNO

Has there been a change in your health within the last year?*

YESNO

Have you been hospitalized or had a serious illness in the last three years?*

YESNO

If YES, explain?

Are you being treated by a physician now? For what?*

YESNO

Are you being treated by a physician now? For what?

Physician's Name and Phone No.

Have you had problems with prior dental treatment?*

YESNO

If YES, please explain

Date of last Dental Exam*

Date

Any prior orthodontic treatment (retainers, braces, expander, etc.)*

YESNO

If so, when & where?

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

Heart Problems? If so, what?*

YESNO

If so, what?

If YES on any of the above: Treating Physician's Name & Phone No.

Rheumatic fever?*

YESNO

Stroke, hardening of arteries?*

YESNO

High blood pressure?*

YESNO

Asthma, TB, emphysema, other lung disease?*

YESNO

Hepatitis, other liver disease?*

YESNO

Family history of diabetes, heart problems?*

YESNO

Psychiatric care?*

YESNO

Radiation treatments?*

YESNO

Chemotherapy?*

YESNO

Artificial joint?*

YESNO

Tumors, cancer?*

YESNO

Arthritis, rheumatism?*

YESNO

Jaw popping, clicking, or difficulty opening*

YESNO

Snoring?*

YESNO

Frequent Sore Throat?*

YESNO

Allergies: food, medication, latex, nickel?*

YESNO

If YES please explain

List medications taken

Anemia?*

YESNO

VD (syphilis/gonorrhea)?*

YESNO

Herpes?*

YESNO

Kidney, bladder disease?*

YESNO

Thyroid, adrenal disease?*

YESNO

Diabetes?*

YESNO

HIV/AIDS?*

YESNO

Hospitalization?*

YESNO

Blood transfusions?*

YESNO

Osteoporosis?*

YESNO

Pacemaker?*

YESNO

Surgeries?*

YESNO

Headaches?*

YESNO

Sleep with mouth open?*

YESNO

Tonsils/Adenoids Removed?*

YESNO

Seasonal Allergies:*

YESNO

If YES please explain

List medications taken

III. ARE YOU TAKING:

Recreational drugs?*

YESNO

Drugs, medications, over-the-counter medicines (including aspirin), natural remedies?*

YESNO

Tobacco in any forms?*

YESNO

If Yes, how much

Alcohol?*

YESNO

If Yes, how often

Please list*

IV. WOMEN ONLY

Are you or could you be pregnant or nursing?*

YESNO

Taking birth control pills?*

YESNO

V. ALL PATIENTS

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

YESNO

If Yes, please explain

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

Patient Signature*

Date*

Date

Name*

Date*

Date

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?

MigrainesTension HeadachesOther

How often?

Top of Head

LEFTRIGHT

Forehead

LEFTRIGHT

Back of Head

LEFTRIGHT

Pain in Head

LEFTRIGHT

Pain in Ear

LEFTRIGHT

Dizziness (vertigo)

LEFTRIGHT

Pain in Jaw Joint

LEFTRIGHT

Temples

LEFTRIGHT

Behind Eyes

LEFTRIGHT

Pain in Shoulder

LEFTRIGHT

Ear Congestion

LEFTRIGHT

Tinnitus (ringing in ears)

LEFTRIGHT

Facial Pain (non-specific)

LEFTRIGHT

Grating sound in joint

LEFTRIGHT

Clicking or popping in jaw joint

LEFTRIGHT

Partial inability to open mouth

NoYesConstantSporadic

Face muscle twitch

NoYes

Difficulty swallowing

NoYes

Difficulty breathing through nose

NoYes

Diffculty chewing

NoYes

Have you ever worn braces

NoYes

Age when braces were on

Orthodontist

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:

BMI

(dividing weight in pounds (lb) by height in inches (in) squared and multiplying by a conversion factor of 703)

Do you snore?

NoYes

Are you excessively tired during the day?

NoYes

Have you been told you stop breathing during sleep?

NoYes

Do you have a history of hypertension?

NoYes

Is your neck size greater than... (17 inches - male | 16 inches female)

NoYes

Orthodontic Registrations

Person Responsible for This Accout

HEALTH HISTORY

HEADACHE AND FACIAL PAIN SCREENING QUESTIONNAIRE

SLEEP APNEA EVALUATION