Download DOC - Lewis Orthodontics

Patient Information Sheet
First Appointment:
Nickname:
Email Address:
Patients Address:
Telephone:
School/Employer:
Grade/Position:
Interest/Sports
 Mother
Primary
 Father
 Step Parent
 Self
 Other (specify)
Responsible Party:
Telephone:
Address:
How Long?
Employer/Address:
Telephone:
Social Security Number:
 Mother
Secondary
 Father
 Step Parent
 Self
 Other (specify)
Responsible Party:
Telephone:
Address:
How Long?
Employer/Address:
Telephone:
Social Security Number:
How Did You Hear About Us?
 Dentist
 Patient
 Relative
 Acquaintance
 Other
Whom May We Thank For Referring You To Us?
Present Dentist:
Reason For Consultation:
Circle Yes or No for which the patient has a history:
Aids
Allergies
Anemia
Arthritis
Aspirin
Asthma
Autoimmune
Bone Disorders
Bulimia
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Cancer
Cerebral palsy
Chest pains
Chronic neck pain
Clicking of jaw
Cold Sores/Herpes
Diabetes
Downs Syndrome
Drug allergies
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Endocrine problems
Emotional disorders
Epilepsy
Fainting, Dizziness
Glaucoma
Headaches
Heart condition
Hepatitis
High Blood Pressure
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Immune problems
Kidney problems
Low Blood Pressure
Mouth breathing
Muscular disorders
Nervous Disorders
Organ Transplant
Painful chewing
Periodontal problems
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Pneumonia
Pregnant
Prolonged Bleeding
Rheumatic Fever
Scoliosis
Seizures
Sicca
Speech problems
TMJ problems
Y N
Y N
Tooth Grinding
Tuberculosis
Venereal Disease
Y N
Y N
Y N
Y N
Y N
Y N
Any disease, problems, or allergies not mentioned above?
Current Medications?
Females: Have you started Menstruating?
Have wisdom teeth been extracted?
At what age?
Any face, mouth or teeth injuries?
Does the patient normally breathe through the mouth while awake or asleep?
Has an orthodontist been consulted previously?
Are there any missing or extra teeth?
Do gums bleed when brushed or flossed?
Have you had previous orthodontic treatment?
Have the Tonsils and adenoids been removed?
Any other questions?
Are you a smoker?
Names and Ages of Brothers & Sisters:
Insurance Information
(Please fill out completely so we may properly file your insurance)
Name of Primary Orthodontic Insurance:
Name of Policy Holder:
Telephone:
 Mother
 Father
 Step Parent
 Mother
 Father
 Step Parent
 Self
 Other (specify)
Policy Holders Birthdate:
Name of Secondary Orthodontic Insurance:
Name of Policy Holder:
Telephone:
 Self
 Other (specify)
Policy Holders Birthdate:
Signature:
Relationship To Patient:
Date:
Y N
Y N
Y N