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Welcome to the Orthodontist Kowalczyk Orthodontics 2752 Forgue Dr., Suite 106 Naperville, IL 60564 Welcome to our office. Please fill out both sides of this form. Patient’s name __________________________________________ Age _________ Birthdate ______________________ Sex _____________ Address ___________________________________________________________________ Phone # __________________________________ STREET CITY ZIP CODE Employer or school __________________________________________________________Business Phone # ___________________________ Person(s) responsible for financial matters (if other than patient): Name __________________________________________________ ____________________________________________ Address _________________________________________________ ____________________________________________ City, State _______________________________________________ ____________________________________________ Work phone ______________________________________________ ____________________________________________ Primary orthodontic Insurance: Secondary orthodontic Insurance: Insurance co. name __________________________________________ ____________________________________________ Insurance co. address ________________________________________ ____________________________________________ Insurance co. phone # ________________________________________ ____________________________________________ Group # (plan, local, or policy#) ________________________________ ____________________________________________ Policy owner’s name _________________________________________ ____________________________________________ Relationship to patient ________________________________________ ____________________________________________ Policy holder’s birthdate ______________________________________ ____________________________________________ Social Security # ____________________________________________ ____________________________________________ Policy holder’s employer _____________________________________ ____________________________________________ Family dentist Name ________________________ Family Physician Whom can we thank for referring you? _______________________________ ___________________________________ Family History (if a minor): Father’s name ___________________________________________________ Living? No Yes Mother’s name __________________________________________________ Living? No Yes Occupation ________________________ Occupation ________________________ Siblings (name and age): ______________________________________________________________________________ Marital status of parents ____________________________ Patient living with: mother father other: ______________ Medical and Dental History Has the patient ever had: AIDS Cold sores Heart condition Oral ulcer Allergy (describe below) Diabetes Head or face injury Previous surgery (describe below) Anemia Endocrine problems Hepatitis Rheumatic fever Arthritis Emotional problems Herpes Thyroid problems Asthma Epilepsy/seizures Kidney disease Other (describe below) Bleeding Hearing problems Lung Disease Comments: ___________________________________________________________________________________________________________ Is the patient under the care of a physician (other than routine care)? No Yes Does the Patient require premedication for dental procedures No Yes Present medications_______________________________________ Condition____________________________________ Birth defects_____________________________________________ Does the patient: 1. Breathe through the mouth? No Yes 2. Snore? No Yes 3. Have frequent colds? No Yes 4. Have “stuffy nose” frequently? No Yes 5. Have frequent sore throats or tonsillitis? No Yes 6. Have difficulty chewing or swallowing? No Yes Any unusual dental experiences? Please explain_____________________________________________________________________________ Does the Patient: 1. Have difficulty in mouth opening? No Yes 2. Have pain, popping, or clicking in the jaw joint(s)? No Yes 3. Have pain with chewing, yawing, or wide opening? No Yes 4. Have pain in or around the ears or cheeks? No Yes 5. Have an uncomfortable bite? No Yes 6. Have a jaw that locks? No Yes Habits 1. Thumb/finger/lip sucking until ________ (age) 2. Clenching or grinding of teeth No Yes 3. Tongue Thrusting or other functional problem No Yes Orthodontic History Has the patient had previous orthodontic consultation(s) No Yes or treatment? No Yes Date: _____________________________________________ Dr.: ______________________________________________________ Why is this consultation being sought? _____________________________________________________________________________________ Signature of individual completing this form: ___________________________________________________Today’s date:__________________
