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Nguyen Orthodontics
509-1110 Sheppard Ave E Toronto ON M2K 2W2 – 416-222-5580
PATIENT ACQUAINTANCE FORM (Child)
PATIENT:
Name ___________________________________________________ Date of Birth ________________ Sex:F___ M___
Day/Month/Year
Address ______________________________________________________ Res Phone _______________________
Employer _________________________ Occupation: _________________ Bus Phone _______________________
FATHER/GUARDIAN (Circle One)
Name _________________________________________________________ Res Phone _______________________
Address: Same as patient_____ or __________________________________________________________________
Employer _________________________ Occupation: _________________ Bus Phone _______________________
MOTHER/GUARDIAN (Circle One)
Name _________________________________________________________ Res Phone _______________________
Address: Same as patient_____ or __________________________________________________________________
Employer _________________________ Occupation: _________________ Bus Phone _______________________
PERSON RESPONSIBLE FOR ACCOUNT
Self ________ Spouse ______ Other _______ Please specify _____________________________________________
INSURANCE AND GENERAL INFORMATION
Does Patient Have Dental Insurance that covers Orthodontic Treatment?
Yes____ No ____
Subscriber's Name: ________________________________________ Name of Ins Co: ________________________
Group of Policy No: ________________________________________ SIN __________________________________
Physician _______________________ Dentist: __________________ Referred by: ___________________________
MEDICAL HISTORY
Is patient in excellent health? Yes ____ No ____ (If no, give reason)
Is patient under care of a physician? Yes ____ No ____ Reason ___________________________________________
Is patient currently taking any medication? Yes ____ No ____
(If yes, please list) ______________________________________________________________________________
Does Patient wear contact lenses? ....... Yes____ No _____
Does patient have a history of:
Diabetes .......................................... Yes ____ No ____
Heart Trouble ................................... Yes ____ No ____
Rheumatic Fever ............................... Yes ____ No ____
Bone Disorders ................................. Yes ____ No ____
Congenital Abnormalities ................... Yes ____ No ____
Tuberculosis ..................................... Yes ____ No ____
Blood disorders ................................. Yes ____ No ____
Anemia ............................................ Yes ____ No ____
Prolonged bleeding ............................ Yes ____ No ____
Frequent colds .................................. Yes ____ No ____
Ear infections ................................... Yes ____ No ____
Tonsillitis ......................................... Yes ____ No ____
Tonsillectomy ................................... Yes ____ No ____
Adenoid problems ............................. Yes ____ No ____
Adenoidectomy ................................. Yes ____ No ____
Allergies (if yes, please list)................ Yes ____ No ____
______________________________________________
Epilepsy ......................................Yes ____ No ____
Gland or Endocrine Problems .........Yes ____ No ____
Fainting or dizziness .....................Yes ____ No ____
Nervous disorders ........................Yes ____ No ____
Emotional Disorders .....................Yes ____ No ____
Liver Problems .............................Yes ____ No ____
Hepatitis .....................................Yes ____ No ____
If Yes to above please specifiy........ A___ B___ C___
Kidney problems ..........................Yes ____ No ____
Frequent sore throats ...................Yes ____ No ____
Pneumonia ..................................Yes ____ No ____
Asthma .......................................Yes ____ No ____
Chronic nasal obstruction ..............Yes ____ No ____
HIV/AIDS ....................................Yes ____ No ____
Other (specify)_______________________________
___________________________________________
DENTAL HISTORY
Any injuries to the head or jaws? --------------- Yes ____ No ____
(If yes please specify) _________________________________
Have you been informed of any missing or extra teeth?Yes ____ No ____
Have you had any teeth extracted? ------------- Yes ____ No ____
Has an orthodontist been consulted previously? Yes ____ No ____
Has either parent had orthodontic treatment - Yes ____ No ____
Has patient any history of:
Thumb sucking ----------------------------------- Yes ___ No___ Tooth grinding ---- Yes ____ No ____
Finger sucking ------------------------------------ Yes ___ No___ Tooth clenching --- Yes ____ No ____
Lip biting ----------------------------------------- Yes ___ No___ Tongue thrusting - Yes ____ No ____
Nail biting ---------------------------------------- Yes ___ No___ Mouth breathing -- Yes ____ No ____
Speech difficulty --------------------------------- Yes ___ No___ Leaning on chin or face Yes __
No ____
Jaw clenching under stress ---------------------- Yes ___ No___ Night grinding ----- Yes ____ No ____
Has patient ever received treatment for any of the above problems? Yes ____ No ____
(If yes, please specify) ___________________________________________________________________________
Does patient have regular dental checkups? --- Yes ___ No ____
Date of last checkup: ________________________________
Tooth brushing:
After every meal ------- Yes ___ No ____
Once per day ------------------- Yes ___ No ____
Twice per day ------------------- Yes ___ No ____
Other
------------------------- Yes ___ No ____
MISCELLANEOUS
List any musical wind instruments played: ____________________________________________________________
List any sports regularly participated in: ______________________________________________________________
Has patient reached puberty? Yes ____ No ____
Girls: When was onset of menstruation? _______________________________________________________
Boys: When did his voice change? ____________________________________________________________
Is patient self conscious of teeth?
Yes ____ No ____ Indifferent ____
Does patient want treatment?
Yes ____ No ____ Indifferent____
Reason for requesting orthodontic consultation?________________________________________________________
Does anyone in the family have a similar problem?
(Please specify)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________________
Signed (Parent or Guardian if patient is under 18 years)
Date:
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