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Download Welcome to Our Office - John B Harrison, DDS MSc
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545 - 4th Avenue South St. Petersburg, Florida 33701 (727) 822-3156 Welcome to Our Office 168 - 14th Street S.W., Suite A Largo, Florida 33770 (727) 822-3156 John B. Harrison, D.D.S., M.Sc. Orthodontist Name_________________________________________________ Sex M F Date ______ / ______ / ______ Age ______ Birthdate ______ / ______ / ______ Marital Status S M W D Nickname________________________________ Address___________________________________________ City____________________________________ Zip______________ Phone _____________________________ / _____________________________ / _____________________________ Home Cell Business Email Address ________________________________________________________________________________________________ Employed By ___________________________________________ Occupation__________________________________________ School _____________________________________________________________________ Grade______________________ Hobbies / Sports______________________________________________________________________________________________ Brother/Sister (Names & Ages)_________________________________________________________________________________ Has anyone else in the family been treated in this office?________________________________________________________ Has patient had previous orthodontic consultation or treatment?_________________________________________________ Whom may we thank for referring you?_________________________________________________________________________ What is it about your teeth/bite and/or appearance that has brought you to see us today?_________________________ ______________________________________________________________________________________________________________ PARENT /SPOUSE INFORMATION Father/Husband Mother/Wife Name________________________________________________ Name_______________________________________________ Address_____________________________________________ Address_____________________________________________ Employed By_________________________________________ Employed By________________________________________ Occupation__________________________________________ Occupation__________________________________________ Phone ______________________ / ______________________ Home Business/Cell Phone______________________ / ______________________ Home Business/Cell Person responsible for account________________________________________________________________________________ Name/billing address if different Do you have orthodontic insurance coverage? Yes No D o you have a Flex Plan? Yes No Filing Date__________________________________ Insurance Company ______________________ ID Number ______________________ Phone__________________________ Employer ____________________________________________ Employer Address ______________________________________ Employer Phone_____________________________________ Policy Holder’s Birthday___________________________ (continued on reverse side) DENTAL How does the patient feel about wearing “braces”?______________________________________________________________ Does anyone else in family have a similar orthodontic problem? Yes No Patient’s Dentist_______________________________________________________________________________________________ Does patient receive regular dental checkups? Yes No Is patient satisfied with past dentistry? Any unfavorable dental experiences?___________________ Yes No Last dental exam_______________________________ ______________________________________________________________________________________________________________ Does the patient have a history of any of the following? Thumb/finger sucking Food traps Nail biting Cold Sores/Abscesses Gum disease/bleeding gums Mouth breathing Missing teeth/extra teeth Noise/discomfort with jaw joint Sensitive teeth (hot/cold) Clenching/grinding of teeth Head/neck/dental injury Speech problems Tongue Thrust Snoring Difficulty sleeping Poor dietary habits MEDICAL Patient’s Physician____________________________________________________ Phone_________________________________ Last exam____________________________ Patient’s overall health status? Excellent Good Poor Is the patient allergic to anything (Drugs, Food s , Pollen, Latex, Metals, Plastics)?_______________________________ Is patient presently under medical care? Yes No________________________________________________________ ______________________________________________________________________________________________________________ Drugs or medications now being taken and reason?____________________________________________________________ ______________________________________________________________________________________________________________ For your protection as well as the protection of others. Has the patient had any of the following? (Please Circle) Adenoids removed AIDS/HIV positive Alcohol/drug addiction Arthritis Asthma Accident/injury Bleeding disorders Cancer Cosmetic surgery Diabetes Epilepsy/seizures Handicaps/Disabilities Hearing Impairment Heart problems Hepatitis High blood pressure Immune disorders Kidney problems Liver problems Lung problems Major surgery Medical emergency Nasal airway problems Rheumatic fever Sexually transmissible disease Tobacco usage Tonsils removed Tuberculosis Tubes in ears Is there any other information you think we should know about to improve your experience with our office? ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ___________________________________________________________________ PATIENT OR PARENT’S SIGNATURE ___________________________________ DATE
