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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 :