Download Now! - Dr Kenmuir Orthodontist

DR. CRAIG KENMUIR
B.D.S.,M.DENT. (Witwatersrand)
ORTHODONTIST
Hilton Orthodontic Practice
Mondi House
380 Old Howick Road
Hilton, 3245
Tel/Fax: (033) 343 3738
Kloof Medical Centre
12 Lyngarth Road, Kloof, 3610
Tel: (031) 764 0909 Fax: (031) 7640910
Email: [email protected]
ADULT PATIENT INFORMATION:
FIRST NAMES:
SURNAME:
DATE OF BIRTH:
RESIDENTIAL ADDRESS:
AGE:
MALE
YEARS
FEMALE
MONTHS
ID NUMBER:
CODE
CELL:
EMAIL:
NEXT OF KIN:
RELATIONSHIP TO PATIENT:
ADDRESS:
TEL:
FAX:
OCCUPATION:
EMPLOYER:
BUS ADD:
TEL:(W)
FAX:
MARITAL STATUS
MARRIED
DIVORCED
DENTISTS NAME:
WHO REFERRED YOU TO THIS PRACTICE:
MEDICAL DOCTORS NAME:
TEL: (H)
CELL:
WIDOWED
(W)
SINGLE
TEL:
SEPERATED
TEL:
PERSON RESPONSIBLE FOR ACCOUNT/PRINCIPLE MEMBER OF MEDICAL AID
TITLE:
SURNAME:
FIRST NAMES:
RELATIONSHIP TO PATIENT:
RESIDENTIAL ADDRESS:
POSTAL ADDRESS:
CODE:
CODE:
TEL:
FAX:
EMPLOYER:
OCCUPATION:
BUSINESS ADDRESS:
CELL:
EMAIL:
TEL:
MEDICAL AID NAME:
IDENTITY NO/PASSPORT NO:
FAX:
NUMBER:
SIGNATURE:
I, THE ABOVE SIGNED, TAKE FULL RESPONSIBILITY FOR PAYMENTOF ALL ACCOUNTS WITHIN 30 DAYS
MEDICAL HISTORY (Please put x in the correct box)
PRESENT HEALTH
EXCELLENT
GOOD
APPETITE
EXCELLENT
GOOD
Have you ever been under the care of a physician during the past two years
(If so, state condition and duration)
FAIR
FAIR
POOR
POOR
YES
Check any of the following for which you may have been treated. State age and if severe
YES
NO
YES
NO
Diabetes
Tuberculosis
Pneumonia
Anaemia
Heart Trouble
Epilepsy
Rheumatic Fever
Asthma
Bone Disorders
Kidney
Involvement
H.I.V. Positive
A.I.D.S.
NO
YES
NO
Endocrine Problems
Prolonged Bleeding
Fainting or Dizziness
Nervous Disorders
Liver Involvement
YES
Do you have tendency to colds
Sore throat
Have Tonsils or Adenoids been removed? If so what age:
List any other serious illnesses not mentioned above
NO
Ear Infections
List any drugs or medications now being taken give reasons
List any allergies or drug sensitivity:
DENTAL HISTORY
YES
NO
Have there been any injuries to the:
Face
Mouth
Teeth
Has the patient ever sucked a thumb or fingers?
Does the patient have speech problems?
Is the patient a mouth breather? While awake?
While Asleep?
Where any teeth removed at any time by a dentist?
Which teeth
Age:
Does patient Grind the teeth
Or Bite their lip
Have you been informed of any missing
Or extra
Permanent teeth?
Has an orthodontist been consulted previously?
Does face and mouth resemble:
Father
Mother
Neither
Does patient desire treatment?
Did mother
Or Father
Have an orthodontic problem?
Do you have regular dental treatment?
What is your main reason for seeking an orthodontic opinion?
Other Relevant information:
Benefits of Orthodontics
Aesthetics Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general
function of the teeth and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to
treatment. If good oral hygiene is not practised, tooth decay and enlarged gums can result. Joint discomfort and root shortening are
observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of the teeth and
some change after treatment.
I have read and understood this paragraph. I also understand that my diagnostic records and my name may be used for educational
and promotional purposes. I have truthfully answered all the above questions and agree to inform this office if any changes in my
medical and dental history. In addition, I authorize Dr Kenmuir to perform a complete orthodontic evaluation.
Sign :
Date :