Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Patient`s Name: I prefer to be called: ______
Transcript
Today’s Date: ________________ Patient’s Name: ________________________________________________________________________ Last Sex: M F First MI I prefer to be called: __________________________ SS#: ________________________ Home Address_______________________________________________________ Street Marital Status (circle one): City Single DOB: _____________________ Cell #: _____________________ Widowed State Separated Married __________________ Zip Home # Divorced Employer: __________________________Occupation: ___________________ Work #: ____________________________ E-mail: _______________________ Employer address: _______________________________________________________________________________________________ How long there? _____________________ Where & when are best times to reach you? ________________________ Our family members seen by us? ____________________________________________________________________ Person Responsible For Account Name: _________________________________________________________________________________________ Billing Address:__________________________________________________________________________________ Street City State Zip DOB:________________ Employer:_____________________________ Home #:___________________________ Cell #__________________________ Work #: ____________________ E-mail: ___________________________ SS #:_____________________________ Driver’s License #: __________________________________________ Insurance Information Insured’s Name: _____________________________________ Insurance Co.:____________________________________________ Group #: ___________________________________________ Insured’s Employer: _______________________________________ Do you have orthodontic insurance? Yes No Don’t Know Any Secondary Insurance for Orthodontics? _________________________________________________________________________ Whom may we Thank for referring you? ____________________________________________________________ Medical History Your current health is : ( ) Good ( ) Fair ( ) Poor Are you currently under the care of a physician? ( ) Yes ( ) No Please explain: ______________________________________________________________________________________________ Are you taking any prescriptions/over the counter drugs? ( ) Yes ( ) No Please list each one: __________________________________________________________________________________________ For Women: Are you taking birth control? ( ) Yes ( ) No 1) Are you pregnant? ( ) Yes ( ) No Are you nursing? ( ) Yes ( ) No Have you ever had any of the following diseases or medical problems? (circle all that apply): Asthma Anemia/Radiation Treatment Artificial Valves Arthritis Blood Transfusions Fever Blisters/Herpes Heart Attack/ Stroke Heart Surgery/Pacemaker Hepatitis Cancer Blood Disease Learning Problems Mumps Rheumatic/Scarlet Fever Chicken Pox Hearing Problems Liver Problems Kidney Problems HIV +/ AIDS Mitral Valve Prolapse Psychiatric Problems Seizures Diabetes Emphysema/Glaucoma Hemophilia Abnormal Bleeding Tumors Hospitalized for any reason Epilepsy Kidney Infections Mental Conditions Sight Problems Spleen Problems Venereal Disease Shingles Ulcers/ Colitis 2. Are you allergic to any of the following? (circle all that apply): Aspirin Penicillin Tetracycline Any metal / plastic Dental Anesthetics Latex Erythromycin Other: ____________________________________________________ Foods: __________________________________________________ Have you ever been told you require Antibiotic pre-medication prior to a dental appointment? Yes No If so, why? _________________________________________________________________________________________________ Dental / Orthodontic History Your Current Dentist:____________________________________________________________________________________ What are your main concerns that you would like the orthodontist to accomplish? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Has your child ever been evaluated for or had any orthodontic treatment? Yes No Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD) Yes No Have you ever had serious problems associated with any previous dental work? Yes No do you like your smile? Yes No Do your gums ever bleed? Yes No Have there been any injuries to the face, mouth, teeth or chin? Yes No If so, describe & when:________________________________________________________________________________________ Are you aware of having any extra and/or missing teeth? Yes No ___________________________________________________________________________________________________________ Have the following been removed: Tonsils or Adenoids (circle all that apply) Yes No Do you have any speech problems? Yes No Do you generally breathe through your mouth : ( ) Awake ( ) Asleep ? Do you snore ? Yes NO Do you know of any other family member or friend who would benefit from orthodontic treatment? Name Phone Number ________________________________________________ ___________________________________ ________________________________________________ ___________________________________ ________________________________________________ ___________________________________ I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and that it is my responsibility to inform this office of any changes to my medical status. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may at the discretion of this office, use the services of one or more credit reporting services. I authorize the dental staff to perform the necessary dental services I may need. __________________________________________________________ Patient Signature _____________________________ Relationship to Patient _______________ Date I have reviewed the health questionnaire with the patient. Signature of Dentist Date
