Download PATIENT INFORMATION: WHO MAY WE THANK FOR REFERRING

EMAIL [email protected] WEB vanlaeckenortho.com
Completing this form in advance and bringing it with you to your
appointment will save you a considerable amount of time. Thank you!
PATIENT INFORMATION:
DATE
WORK PHONE
PATIENT’S NAME
EMAIL
(FIRST, MIDDLE INITIAL, LAST, PREFERRED NAME)
BIRTH DATE
ADDRESS
(STREET, CITY, STATE, ZIP CODE)
AGE
HOME PHONE
DENTIST
CELL PHONE
GENDER
MALE
FEMALE
WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE?
OFFICE STAFF (NAME)
DENTIST (NAME)
FRIEND (NAME)
SIGNAGE
WEBSITE/
INTERNET
INVISALIGN
SCHOOL
PROMOTION/
DIRECT MAILING
RESPONSIBLE PARTY INFORMATION:
SELF OR PARENT/GUARDIAN IF UNDER 18
SELF OR PARENT/GUARDIAN IF UNDER 18
ADDRESS
ADDRESS
HOME PHONE
HOME PHONE
CELL PHONE
CELL PHONE
WORK PHONE
WORK PHONE
EMAIL
EMAIL
BIRTH DATE
BIRTH DATE
RELATIONSHIP TO PATIENT
RELATIONSHIP TO PATIENT
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
EMPLOYER
EMPLOYER
INSURANCE COMPANY
INSURANCE COMPANY
INSURANCE COMPANY ADDRESS
INSURANCE COMPANY ADDRESS
INSURANCE POLICY/GROUP NUMBER
INSURANCE POLICY/GROUP NUMBER
INSURANCE ID NUMBER
INSURANCE ID NUMBER
(FIRST, MIDDLE INITIAL, LAST)
(STREET, CITY, STATE, ZIP CODE)
(FIRST, MIDDLE INITIAL, LAST)
(STREET, CITY, STATE, ZIP CODE)
SPORTS TEAM/
SPONSORSHIP
EMAIL [email protected] WEB vanlaeckenortho.com
I agree that Ryan K. VanLaecken D.D.S., M.S., Rob S. VanLaecken, D.D.S., M.S. or Robert A. Arnold, D.D.S., M.S. may access any credit
references and/or credit reports that they deem necessary. I understand that VanLaecken Orthodontics provides only an estimate of
the amount that the insurance policy may pay, and I will be responsible for the portion of the fee that insurance does not cover. I hereby
authorize release of information relating to this and future insurance claims (including the addition of insurance at a later date) to the
above named orthodontists.
Signature (Parent/Guardian signature if minor)Date
For Office Use Only
Conf. Date:
Benefit Amt:
Age Limit:
Deductible:
Pymt. Interval: M Q S A
Benefit Remaining:
% of fee charged:
Auto/Non Auto: Other
Staff:
MEDICAL HISTORY:
IS IT NECESSARY TO PRE-MEDICATE PATIENT BEFORE APPOINTMENT?
YES
NO
IS THE PATIENT UNDER THE CARE OF A PHYSICIAN NOW?
YES
NO
IF SO, WHAT CONDITION
NAME OF PHYSICIAN
MEDICAL HISTORY
MEDICATIONS
(PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING OR HAVE TAkEN IN THE
LAST SIX MONTHS INCLUDING HEART OR BLOOD PRESSURE, CORTISONE, ANTICANCER,
ANTIFUNGAL, ANTIBIOTIC, OSTEOPOROSIS/BONE LOSS TREATMENT OR MEDICATIONS)
(LIST PAST AND CURRENT, INCLUDING HEART MURMUR, RHEUMATIC FEVER,
MITRAL VALVE PROLAPSE SYNDROME, HYPERTENSION, HEMODIALYSIS,
JOINT REPLACEMENT, HEMOPHILIA, ASTHMA, GLAUCOMA)
VIRAL INFECTIONS
HOSPITALIZATIONS
(LIST PAST AND CURRENT INCLUDING HERPES SIMPLEX, MONONUCLEOSIS,
SHINGLES, HEPATITIS, AIDS)
DOES THE PATIENT USE TOBACCO PRODUCTS?
(PLEASE LIST ALL)
YES
NO
IF SO, LIST FREQUENCY OF USE AND APPROXIMATE QUANTITY OF USE
RECENT INJECTIONS OTHER THAN
DENTAL, TETANUS, ETC. (DATE)
TRANSFUSIONS: (DATE)
ARE THERE ANY OTHER CONDITIONS, SYNDROMES OR HEALTH ISSUES NOT LISTED?
ALLERGIES TO DRUGS: (IE. PENICILLIN, LOCAL ANESTHETICS)
DO YOU HAVE A FREQUENT
“STUFFY NOSE”?
YES
NO
ALLERGIES TO FOOD:
DO YOU HAVE A FREQUENT
SORE THROAT OR TONSILITIS?
YES
NO
ALLERGIES TO SEASONAL THINGS:
DO YOU HAVE DIFFICULTY
CHEWING OR SWALLOWING?
YES
NO
ALLERGIES TO OTHER THINGS: (IE. NICKEL, LATEX)
HAVE YOU RECEIVED MEDICAL TREATMENT FROM AN
ALLERGIST OR EAR, NOSE & THROAT SPECIALIST?
YES
DO YOU BREATHE THROUGH YOUR MOUTH?
SELDOM
SOMETIMES
NO
IF SO, WHEN?
USUALLY
IF SO, BY WHOM?
DO YOU SNORE WHEN SLEEPING?
YES
NO
DO YOU HAVE FREQUENT COLDS?
YES
NO
NASAL
SURGERY
TONSILS
REMOVED
ADENOIDS
REMOVED
EMAIL [email protected] WEB vanlaeckenortho.com
DENTAL AND TEMPOROMANDIBULAR JOINT HISTORY
HAS THE PATIENT HAD ANY UNUSUAL DENTAL EXPERIENCES?
YES
NO
YES
NO
IF YES, PLEASE SPECIFY:
HAS THE PATIENT HAD ANY INJURIES TO THE MOUTH, TEETH OR JAW?
IF YES, PLEASE SPECIFY:
WERE THE PATIENT’S TEETH
CLEANED AT THIS TIME?
DATE OF LAST DENTAL VISIT:
HAS THE PATIENT EVER RECEIVED
A SEVERE BLOW TO THE TEETH OR JAW?
YES
NO
HAS THE PATIENT HAD
AN ORTHODONTIC
CONSULT/TREATMENT?
HAS ANYONE ELSE IN THE PATIENT’S
FAMILY HAD ORTHODONTIC TREATMENT?
YES
NO
IS THE PATIENT ADOPTED?
WHO DOES THE PATIENT LOOK MOST LIKE?
MOTHER
FATHER
YES
NO
YES
NO
YES
NO
DOES THE PATIENT HAVE:
HEADACHES
NECK PAIN
JAW PAIN
IF SO, WHICH SIDE HURTS?
RIGHT
EAR PAIN
FACE PAIN
OTHER
EYE PAIN
IF SO, HOW LONG HAVE THESE SYMPTOMS BEEN PRESENT?
MONTHS
YEARS
BOTH
LEFT
DAYS
IS THE PAIN:
CONSTANT
ACHING
SHOOTING
STABBING
ELECTRICAL
WORSE IN THE
MORNING
WORSE IN THE
AFTERNOON
DOES IT HURT
TO CHEW?
DOES IT HURT
TO OPEN WIDE?
OTHER
DOES THE PATIENT’S JAW EVER MAKE:
A POPPING NOISE
DOES THE PATIENT EVER CLENCH
OR GRIND HIS/HER TEETH?
YES
NO
CLICKING
IF SO, WHEN?
GRINDING
OTHER
DURING THE DAY
DURING THE NIGHT
HAS THE PATIENT’S JAW EVER LOCKED
UP OR SLIPPED OUT OF PLACE?
YES
DOES THE PATIENT HAVE PROBLEMS WITH HIS/HER:
IS IT DIFFICULT OR
PAINFUL TO SWALLOW?
YES
NO
NO
EARS
HEARING
ARE THE TEETH SORE
OR SENSITIVE?
DIZZINESS
YES
OTHER
NO
EMAIL [email protected] WEB vanlaeckenortho.com
DENTAL AND TEMPOROMANDIBULAR JOINT HISTORY CONT’D
DOES THE PATIENT EXHIBIT:
THUMB OR
FINGER SUCKING
TONGUE THRUST
(REVERSE
SWALLOWING)
LIP BITING
NAIL BITING
POOR SPEECH
HABITS
DOES THE PATIENT WANT HIS/HER TEETH STRAIGHTENED?
YES
NO
WHAT IS THE PATIENT MOST CONCERNED ABOUT?
BITE
APPEARANCE
OTHER
FACIAL PROFILE
PATIENT SURVEY FORM
HELP US GET TO KNOW YOU BETTER! FILL OUT THE FOLLOWING SURVEY TO HELP US BETTER SERVE YOU.
WHAT ARE YOUR FAVORITE ACTIVITIES/HOBBIES?
DO YOU LIKE SPORTS?
YES
NO
IF SO, WHAT IS YOUR FAVORITE TEAM?
WHAT IS YOUR DREAM JOB?
WHO IS YOUR FAVORITE SINGER OR BAND?
WHAT IS YOUR FAVORITE TYPE OF MUSIC?
WHAT IS YOUR FAVORITE TV SHOW OR MOVIE?
WHAT IS YOUR FAVORITE FOOD OR RESTAURANT?
DO YOU HAVE A PET?
YES
NO
WHAT IS YOUR FAVORITE VACATION SPOT?
WHAT IS YOUR PET’S NAME?
WHAT COMMUNITY GROUPS/ACTIVITIES DO YOU PARTICIPATE IN?
CONSENT OF PARENT OR LEGAL GUARDIAN TO INITIAL ORTHODONTIC EXAMINATION
I (we) understand, that by signing this, I (we) are providing our consent to VanLaecken Orthodontics and its staff and
personnel to conduct an Initial Orthodontic Examination for:
(Print Patient’s FULL Name)
SIGNATURE
PLEASE PRINT NAME
RELATIONSHIP TO PATIENT
DATE
SIGNATURE
PLEASE PRINT NAME
RELATIONSHIP TO PATIENT
DATE