Download ORTHODONTIC QUESTIONNAIRE AND ACQUAINTANCE FORM

ORTHODONTIC QUESTIONNAIRE AND ACQUAINTANCE FORM
WALTER FELDMAN D.D.S.
Patient’s Name_________________________________________ Date_______________
Male ________ Female _______ Age_____ Birth Date___________
Address_________________________________City________________Zip__________
Phone # _________________________
Cell/Work #___________________________
MOTHER’S INFORMATION
Name_______________________________________Phone_______________________
Address_________________________________City________________Zip__________
Employed By__________________________Birth Date_________ SS#_____________
Employer’s Address_____________________________City____________Zip________
FATHER’S INFORMATION
Name________________________________________Phone______________________
Address_________________________________City________________Zip__________
Employed By______________________Birth Date_________SS#____________
Employer’s Address_____________________________City____________Zip________
INSURANCE INFORMATION
Primary Insurance_________________Cardholder’s Name________________________
Secondary Insurance__________________Cardholder’s Name_____________________
OTHER
Referred By______________________________________________________________
Patient’s Dentist______________________________________Phone_______________
Address__________________________________City_________________Zip________
And now some information about myself…
I graduated from New York University College of Dentistry and entered the armed forces, serving for two years.
I received my orthodontic training at New York University and have been in the exclusive practice of orthodontics since
1976. I am presently a member of the American Association of Orthodontists, as well as the Chief of Department of
Orthodontics at Bellevue Hospital Pediatrics.
MEDICAL HISTORY
For the following questions, please check whichever applies. Your answers are for our
records only and will be considered confidential.
YES
NO
Are you in good health?
____
____
Are you currently under the care of a physician?
____
____
Are you taking any prescription /non-prescription drugs?
____
____
Have you been hospitalized for any reason?
____
____
If yes, please explain_______________________________________________________
Have you any of the following diseases or medical problems?
YES
NO
 Heart Surgery/Pacemaker
 Hemophilia/Abnormal Bleeding
 High/Low Blood Pressure
 Congenital Heart Defect
 Mitral Valve Prolapse
 Allergies/Sinus Problems
 Radiation Treatment
 Severe/Frequent Headaches
 Artificial Bones/Joints/Valves
 Pneumatic Fever
 Epilepsy/Seizures/Fainting Spells
 Rheumatic Fever
YES
NO
 Hepatitis

 Asthma
 Diabetes
 Shingles
 Kidney Problems
 HIV/AIDS
 Anemia

Are you allergic to any medications? If so, please list.
________________________________________________________________________
Are you allergic to any latex, metal, or plastic? If so, please list.
________________________________________________________________________

YES
NO
Do you have any jaw problems?
____ ____
Do you have any pain, popping, clicking, or cracking during
____ ____
jaw movement? (If so, please explain symptom, location, and duration.)
________________________________________________________________________
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
I understand that the information that I have given today is correct to the best of my
knowledge. I also understand that this information will be kept confidential and I will
inform this office of any changes in my medical status.
SIGNATURE_____________________________________________Date___________
Update Signature__________________________________________Date___________
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