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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Patient Information (Please fill out this form prior to your appointment.) Date: ___________________ Name: _________________________________________________________________ Soc. Sec. #_________________________________ Nickname: _____________________ Sex:_________ Date of Birth:_________________ Age:________ Address:___________________________________________________________________________________________________________ Patient Work Phone: ______________________ If a minor, give parent’s or guardian’s name: ______________________ Home Phone: ___________________________ Cell: ____________________________________ Email address: ______________________________ Whom may we thank for referring you? __________________________ General Dentist: ________________________________________ Physician: __________________________________ Reason for Consultation __________________________________________________________________________________________ Have you ever been examined by an orthodontist? Yes No If yes, when? _________ Had Braces? Yes No Siblings’ names & ages: ____________________________________________________________________________________________ Any family members had orthodontics? ___________________ Where? _____________________________________________ School: ________________________________ Grade: ____________ Interests: _____________________________________________ Medical Information Is patient in good health? .........................................................................................................Yes No Does the patient have any history of major illness? .........................................................Yes No Has patient ever been under the care of a physician for illness? ..................................Yes No If yes, give reason: ________________________________________________________________________________________________ Has puberty been reached (menstruation or voice change)? _____________________________________________________ Check any of the following for which the patient has been treated or diagnosed with: Heart Complications High Blood Pressure Low Blood Pressure Rheumatic Fever Arthritis / Rheumatism Kidney Complications Ulcers Diabetes Thyroid Problems Emphysema Tuberculosis Asthma Latex Sensitivity Allergies Sinus Trouble Cancer Hepatitis A (Infectious) Hepatitis B (Serum) Venereal Disease A.I.D.S. H.I.V. Positive Blood Transfusion Hemophilia/ Prolonged Bleeding Neurological Disorders Epilepsy or Seizures Fainting/Dizzy Spells Nervous/Anxious Pneumonia Bone Disorders Herpes/Cold Sores Anemia Psychiatric/ Psychological Care Periodontal Disease Endocrine Problems Liver Involvement Hypoglycemia Does patient take any bisphosphonate medications for osteoporosis, such as Fosamax? _________________________ Does the patient have a tendency to colds? Yes No Sore Throats? Yes No Have tonsils and/or adenoids been removed? Yes No Ear Infections? Yes No At what age? __________________ List any drugs or medications now being taken and give reasons: _______________________________________________ ____________________________________________________________________________________________________________________ List any allergies or drug sensitivity: ____________________________________________________________________________ Dental History Have you had any injuries to the face, mouth or teeth? ....................................................Yes No Habits: Thumb or finger sucking..............................................................................Yes No Mouth Breathing ...........................................................................................Yes No Nail/Lip Biting ..............................................................................................Yes No Grinding or Clenching of Teeth...................................................................Yes No Tongue Thrusting...........................................................................................Yes No Have you been informed of any missing or extra permanent teeth? .............................Yes No -Over Please- Financially responsible Party Information Name: Ms. Mrs. Miss. Mr. Dr. ______________________________________________________________________ Married Single Separated Divorced Widowed Residence: _________________________________________________________________________________________________________ Mailing Address: _________________________________________________________________________________________________ How long at this address: _____ Home Phone: _______________Cell: ________________Work Phone: _________________ Previous Address (if less than 3 years): ___________________________________________________________________________ Social Security# _____________________Birthdate: ________________________ Relationship to Patient ________________ Employer: ______________________________ Occupation: ___________________ No. Years Employed: __________________ Spouse’s Name: _________________________________________________________Relationship to Patient: _________________ Employer: ______________________________ Occupation: ___________________ No. Years Employed : __________________ Social Security# _____________________Birthdate: ________________________ Work Phone: ___________________________ Insurance Information Do you have orthodontic coverage? Yes No Benefit amount: _________________ If no, skip this section. Insured’s name: ________________________________________________________ Insured’s Soc. Sec. #: _____________________ Insured’s Employer: _____________________________________ Group No. _________________ Local No. _________________ Insurance Company Name & Address: ___________________________________________________________________________ Insurance Company Phone Number: _____________________________________________________________________________ Secondary Insurance? Yes No Benefit amount: _________________ If no, skip this section. Insured’s name: ________________________________________________________ Insured’s Soc. Sec. #: _____________________ Insured’s Employer: _____________________________________ Group No. _________________ Local No. _________________ Insurance Company Name & Address: ___________________________________________________________________________ Insurance Company Phone Number: _____________________________________________________________________________ Emergency Information Name of nearest relative not living with you: ___________________________________________________________________ Complete Address: ________________________________________________________________________________________________ Home Phone: ___________________________ Cell: ____________________________ Work Phone: __________________________ Authorization and Release Please Sign and Initial the following: ________ In accordance with HIPPA regulations, I hereby give my permission for the office of Dr. R. Baker Rawlins to use patient records and information for diagnosis, treatment planning, promotion, education and insurance purposes. ________ I authorize the dentist to release any information including the diagnosis, and records for treatment rendered to me or my child, if necessary for insurance purposes. I also authorize direct payment of insurance benefits to the dentist for services rendered when indicated. ________ I understand that where appropriate, credit bureau reports may be obtained. Signature (Parent’s signature if minor) _________________________________________________ Date __________________ Updates: (date & initial) ___________________ ___________________ CONFIDENTIAL (for record and pretreatment evaluation) ___________________ ___________________