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Welcome to the Orthodontist
Kowalczyk Orthodontics
2752 Forgue Dr., Suite 106
Naperville, IL 60564
Welcome to our office. Please fill out both sides of this form.
Patient’s name __________________________________________ Age _________ Birthdate ______________________ Sex _____________
Address ___________________________________________________________________ Phone # __________________________________
STREET
CITY
ZIP CODE
Employer or school __________________________________________________________Business Phone # ___________________________
Person(s) responsible for financial matters (if other than patient):
Name __________________________________________________
____________________________________________
Address _________________________________________________
____________________________________________
City, State _______________________________________________
____________________________________________
Work phone ______________________________________________
____________________________________________
Primary orthodontic Insurance:
Secondary orthodontic Insurance:
Insurance co. name __________________________________________
____________________________________________
Insurance co. address ________________________________________
____________________________________________
Insurance co. phone # ________________________________________
____________________________________________
Group # (plan, local, or policy#) ________________________________
____________________________________________
Policy owner’s name _________________________________________
____________________________________________
Relationship to patient ________________________________________
____________________________________________
Policy holder’s birthdate ______________________________________
____________________________________________
Social Security # ____________________________________________
____________________________________________
Policy holder’s employer _____________________________________
____________________________________________
Family dentist
Name
________________________
Family Physician
Whom can we thank for referring you?
_______________________________
___________________________________
Family History (if a minor):
Father’s name ___________________________________________________ Living?
No
Yes
Mother’s name __________________________________________________ Living?
No
Yes Occupation ________________________
Occupation ________________________
Siblings (name and age):
______________________________________________________________________________
Marital status of parents ____________________________
Patient living with:
mother
father
other: ______________
Medical and Dental History
Has the patient ever had:
AIDS
Cold sores
Heart condition
Oral ulcer
Allergy (describe below)
Diabetes
Head or face injury
Previous surgery (describe below)
Anemia
Endocrine problems
Hepatitis
Rheumatic fever
Arthritis
Emotional problems
Herpes
Thyroid problems
Asthma
Epilepsy/seizures
Kidney disease
Other (describe below)
Bleeding
Hearing problems
Lung Disease
Comments: ___________________________________________________________________________________________________________
Is the patient under the care of a physician (other than routine care)?
No
Yes
Does the Patient require premedication for dental procedures
No
Yes
Present medications_______________________________________
Condition____________________________________
Birth defects_____________________________________________
Does the patient:
1. Breathe through the mouth?
No
Yes
2. Snore?
No
Yes
3. Have frequent colds?
No
Yes
4. Have “stuffy nose” frequently?
No
Yes
5. Have frequent sore throats or tonsillitis?
No
Yes
6. Have difficulty chewing or swallowing?
No
Yes
Any unusual dental experiences? Please explain_____________________________________________________________________________
Does the Patient:
1. Have difficulty in mouth opening?
No
Yes
2. Have pain, popping, or clicking in the jaw joint(s)?
No
Yes
3. Have pain with chewing, yawing, or wide opening?
No
Yes
4. Have pain in or around the ears or cheeks?
No
Yes
5. Have an uncomfortable bite?
No
Yes
6. Have a jaw that locks?
No
Yes
Habits
1. Thumb/finger/lip sucking until ________ (age)
2. Clenching or grinding of teeth
No
Yes
3. Tongue Thrusting or other functional problem
No
Yes
Orthodontic History
Has the patient had previous orthodontic consultation(s)
No
Yes
or treatment?
No
Yes
Date: _____________________________________________ Dr.: ______________________________________________________
Why is this consultation being sought? _____________________________________________________________________________________
Signature of individual completing this form: ___________________________________________________Today’s date:__________________