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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: