Download DOC - Salmon Orthodontics

Marlin S. Salmon, D.D.S.
Deborah A. deSa, D.M.D.
Professional Corporation
Practice Limited to Orthodontics for Children and Adults
IN ORDER TO PERFORM A MORE COMPLETE SERVICE FOR OUR PATIENTS,
WE ASK YOUR COOPERATION IN COMPLETING THIS QUESTIONNAIRE.
PATIENT INFORMATION
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Patient Name
Soc. Sec. #
Address
Nickname
Street
City/State
Zip
E-Mail Address
Do you wish to have E-mail appointment reminders? Yes □ No □
Do you wish to have Text Message appointment reminders? Yes □ No □
Dentist
Address
Physician
Address
Referred by
School
Play a musical instrument?
F□
Birthdate
Tel. #
Grade
Hobbies
Cell #
Street
City/State
Zip
Street
City/State
Zip
Sports
Interests
RESPONSIBLE PARTY INFORMATION
Father’s Name
Address
How long at this address?
If less than 3 years, previous address
E-Mail Address
Do you wish to have E-mail appointment reminders? Yes □ No □
Do you wish to have Text Message appointment reminders? Yes □ No □
Occupation
Business Name
Soc. Sec. #
Mother’s Name
Address
How long at this address?
If less than 3 years, previous address
E-Mail Address
Do you wish to have E-mail appointment reminders? Yes □ No □
Do you wish to have Text Message appointment reminders? Yes □ No □
Occupation
Business Name
Soc. Sec. #
Person(s) Financially Responsible
Insurance covering orthodontics
Relationship
Carrier
How long?
Cell #
Business Tel. No.
How long?
Cell #
Business Tel. No.
ORTHODONTIC INFORMATION
1.
Reason for orthodontic consultation:
2.
Previous treatment - patient or others in immediate family:
Yes □
No □
If yes, who?
With what results? _____Excellent _____ Good _____Poor
3.
Have you had a previous orthodontic consultation?
Yes □
4.
No □
If yes, with whom?
What do you consider to be the main benefits of orthodontic correction?
_____Cosmetic
_____ Functional
_____Psychological/Emotional
Other
Which are factors in this instance?
5.
Is patient self-conscious of his/her teeth?
Yes □
No □
If yes, please explain
6.
Patient’s attitude toward orthodontic treatment: _____ Enthusiastic
7.
Expected patient cooperation: _____Excellent
8.
Are both parents in favor of treatment?
_____Fair
_____Resentful
_____Poor
No □
Yes □
9.
_____ Good
_____Indifferent
Are parents aware that orthodontic appointments will infringe on school time?
No □
Yes □
MEDICAL HISTORY
1.
Patient size: _____Average
Height _____
_____Large
Weight _____
Father’s Ht. _____
2.
Present state of health: _____Excellent
3.
Currently under physician’s care:
Yes □
4.
_____ Good
Mother’s Ht. _____
_____Fair
Adopted _____
Natural Child _____
_____Poor
No □ Why?
Currently taking medication:
Yes □
5.
_____Small
No □ What?
Is there any patient history: (If you answer yes to any of the following questions, please explain to the right of the question.)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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No □
No □
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No □
No □
No □
No □
No □
No □
No □
No □
No □
Facial accidents?
Facial operations?
Environmental allergies?
Allergies to medication?
Emotional disorders?
Vision impairment?
Hearing problems?
Tonsillitis?
Speech problems?
Blood disorders?
Immune System Disorders?
Birth defects?
Asthma?
Anemia?
Diabetes?
Hepatitis?
Rheumatic Fever?
Yes
Yes
Yes
Yes
Yes
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No □
No □
No □
No □
No □
Epilepsy?
Heart Disease problems including murmurs?
Liver or Kidney disease?
TMJ (jaw joint problems)?
Arthritis?
6.
Serious illness other than usual childhood disorders?
7.
Has the patient ever been hospitalized?
Yes □
8.
No □
If yes, for what and the date:
Is the patient under psychological guidance?
Yes □
No □
If yes, for what?
Mental development: _____ Above Average
_____ Average
_____ Below Average
DENTAL HISTORY
1.
When was patient’s last visit to his/her general dentist?
2.
Has patient had: _____ Previous dental treatment?
_____Extractions?
3.
_____Regular dental check-ups?
_____Impressions?
Has patient ever lost or chipped any teeth?
Yes □
No □ If yes, explain the circumstances
4.
Eruption of teeth: _____Early
5.
Oral hygiene habits: _____Good
6.
Has the patient ever received a blow to the teeth or jaws?
Yes □
7.
_____Average
_____Late
_____Poor
_____Markedly delayed
Intake of sweets: _____High
_____Moderate
_____Low
No □ If yes, please explain:
Indicate habits, past or present, relating to the mouth or face:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
8.
_____X-rays?
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No
No
No
No
No
No
No
No
No
No
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Thumb □ Finger □ Object □ sucking?
Mouth breathing?
Lip biting?
Tongue thrust (reverse swallow)?
Chewing habits?
Nail biting?
Postural habits?
Sleeping habits (blanket sucking)?
Tooth grinding/clenching?
Poor speech habits?
Is there any hereditary background (familial tendency) which might contribute to this orthodontic problem?
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 service.
Signed
Date
(Parent or Guardian)