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Date_______________________ BrokenArrow/Glenpool PATIENTINFORMATION Patient’sName_________________________________________Iprefertobecalled______________Sex____DateofBirth_________ LASTFIRSTMI Patient’sSSN_______________________Age_____SchoolAttending_________________________Dentist_______________________ Howdidyouhearaboutouroffice?_______________________________________DidyouseeourWebsiteorYellowpageadd?(Circle) RESPONSIBLEPARTYINFORMATION Cell#_______________Home#________________Work#________________Email____________________________DOB_______ Name___________________________________________SocialSecurity#_______________RelationshiptoPatient________________ LASTFIRSTMI MailingAddress____________________________________________________,______,__________Howlongatthisaddress?________ STREETCITYSTATEZIP Employer______________________________________Occupation______________________________No.ofYearsEmployed_____ OtherParent/Spouse’sName________________________________________________RelationshiptoPatient__________________ LASTFIRSTMI Employer_______________________________________Occupation_____________________________No.ofYearsEmployed_____ SocialSecurity#______________________________DateofBirth__________________WorkPhone___________________________ ORTHODONTICINSURANCEINFORMATION Insured’sName_______________________________Insured’sSSN_______________InsuranceCompany________________________ GroupNo._______________Insured’sEmployer_____________________________________Ifyouhavedualcoverage,pleaselistyour otherInsuranceCompany_______________________________SecondaryInsured’sName____________________________________ SecondaryInsured’sSSN__________________Employer_______________________________________GroupNo.________________ MEDICAL/DENTALHISTORY FamilyHistoryof(CircleAllthatapply)UnderbiteOverbiteNeitherAdopted? Yes No Girlsunder18:Hasshestartedmenstruation? Yes NoBoysunder18:Hashisvoicechanged? Yes No NamesandagesofPatient’sBrothers_______________________________________Sisters___________________________________ Familymemberspreviouslyinorthodontictreatment____________________________________________________________________ Anymajororunusualillnessesorotherhealthproblems? Yes NoExplain_______________________________________________________ Currentlyunderphysician’scare? Yes NoReason____________________________________________________________________________ Allergies?(Checkthosethatapply)Aspirin_______Nickel_________Latex___________Other____________________________________________ Drugsensitivity?Codeine______Penicillin_________Erythromycin____________Other___________________________________ Hasthepatientevertakenpremedicationforadentalprocedureduetoaheartcondition?_________________________________________________ PleasecheckifPatientHasorHadAnyoftheFollowing: YesNoYesNoYesNoYesNo Anemia Hepatitis HeartValvereplacement Jaundice(Besidesatbirth) BloodDisease Tuberculosis Rheumaticfever Epilepsy ProlongedBleeding Diabetes Malignancies,Tumors,orCancer BoneDisorders AIDSorHIVpositive Asthma TonsilsRemoved:Age:_____ EndocrineProblems Herpes Mitralvalveprolapsedwithregurgitation AdenoidsRemoved:Age:_____ EmotionalStress Hasthepatienthadanysevereheadorfaceinjuries?Explain__________________________________________________________________ Hasthepatienteverhadafinger/thumbsuckinghabit?Isthehabitstillpresent? Yes No.Agehabitstopped____________ Doesthepatientplayanymusicalinstrumentsthatinvolvethemouth?What?____________________________________________________ Hasthepatientconsultedanorthodontistpreviously?Date___________________________Doctor__________________________________ Hasthepatienthadanypreviousorthodontictreatment?Explain?_____________________________________________________________ PLEASECHECKYESORNOFORTHEFOLLOWINGQUESTIONS YesNoYesNoYesNo ClenchingTeeth HighDecayRate JawJointPopping/Clicking GrindingTeeth Headaches(morethannormal) RingingintheEars MuscularSoreness(head&neck) JawJointSoreness TongueThrust SnoringLoudly MouthBreather SpeechProblem/SpeechTherapy Whenwasthepatient’slastvisitwiththeirdentist?_______________________________ Whatdoyouoryourdentistconsidertobeyourmainorthodonticproblem?________________________________________________ ____________________________________________________________________________________________________________________________ Iherebyagreethatalltheaboveinformationisbothaccurateandcurrent.Iunderstandthatwhereappropriate,creditbureaureportsmaybeobtained. Signature(Parentssignatureifminor)__________________________________________Date_______________________________
