Trophy Club Orthodontics Form

Patient Information

Date:

Patient’s name:

Last: Last Name

First: First Name

Middle: Middle Name

Address:

Street

City

Zipcode:

Home Phone:

Contact e-mail address:

Birthdate:

Social Security: #

If patient is a minor, give parent’s or guardian’s name:

Whom may we thank for referring you to our office?

Responsible Party Information

Patient’s name:

Last: Last Name

First: First Name

Middle: Middle Name

Residence:

Street

City

Zipcode:

Mailing Address:

Street

City

Zipcode:

Home Phone:

Work Phone:

Social Security: #

Birthdate:

Relationship to Patient:

Employer:

Occupation:

Dental Insurance Information

Do You Have Insurance?

Yes No

Subscriber #1

Name:

Birthdate:

Employer:

Employer Address:

Street

City

Zipcode:

Employer ID:

Insurance Company:

Phone #:

Group #:

Insurance Company Address:

Street

City

Zipcode:

Medical History

Physician:

Date of Last Visit:

Address:

Phone:

Are you taking any medication? (If Yes, please fill in details)

Yes No

Details:

Are you allergic to any medication? (If Yes, please fill in details)

Yes No

Details:

Do you have a history of a major illness? (If Yes, please fill in details)

Yes No

Details:

Have you had any major operations? (If Yes, please fill in details)

Yes No

Details:

Have you ever been involved in a serious accident? (If Yes, please fill in details)

Yes No

Details:

Check any of the medical conditions below that you have had or currently have.

Abnormal bleeding/Hemophilia

Diabetes

Hepatitis/Liver problems

Pneumonia

Anemia

Dizziness

Herpes

Heart Murmur

Bleeding

Arthritis

Epilepsy

High Blood Pressure

Radiation/Chemotherapy

Asthma or Hayfever

Gastrointestinal Disorders

Tumor or Cancer

Rheumatic Fever

Bone Disorders

Nervous Disorders

Kidney problems

Tuberculosis

Congenital Heart Defect

Are there any medical conditions we have not discussed that you feel we should be aware of?

Check any of the allergies below that you have had or currently have.

Latex

Penicillin

Codeine

Erythromycin

Tetracycline

Aspirin

Ibuprofen

Metals

Other

Check any below that you have had or currently have.

Rheum

Fever

Prosthesis

Convulsions/epilepsy

Hearing impairment

Handicaps/disabilities

History of Scarlet Fever

Check any of the child habits your child have.

Thumb sucking/Finger sucking

Lip Sucking/Biting

Nail biting

Nursing Bottle Habits

Trouble chewing

Dentist:

Date of Last Visit:

What concerns you most about your teeth?

Yes No

Are you presently in any dental pain?

Yes No

Have you ever experienced any unfavorable reaction to dentistry?

Yes No

Have you ever lost or chipped any teeth?

Yes No

Have there been any injuries to face, mouth or teeth?

Yes No

Is any part of your mouth sensitive to temperature or pressure?

Yes No

Do your gums bleed when you brush?

Yes No

Do you have any type of thumb or tongue habit?

Yes No

Are you a mouth breather?

Yes No

Have you ever seen an orthodontist?

If yes, who and when?

Yes No

Would you object to wearing orthodontic appliances (braces) should they be indicated?

Yes No

Has anyone in your family received orthodontic treatment?

How did they feel about the result?

What is your attitude toward receiving orthodontic treatment?

Yes No

Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

Yes No

Are you aware of your jaw clicking or popping?

Yes No

Are you aware of clenching your teeth during the day?

Yes No

Have you ever been told that you grind your teeth?

Yes No

Do you have “tension” headaches?

Yes No

Have you ever experienced chronic ringing in your ears?

Height of parents? Mom

Dad

Yes No

Has menstruation started?

Yes No

Are you aware that some appointments will be during school/work hours?

Please list some hobbies or interests:

Female Patients only:

Yes No

Are you pregnant?

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. to perform a complete orthodontic evaluation.

PATIENT ACKNOWLEDGMENT

Patient/Parent/Guardian Signature

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Patient's Name

D.O.B:

Authorization for release of Protected Health Information to family members, significant others, and/or friends. I authorize release of any and all health information including diagnosis, dental records, digital x-rays, rendered and the release of financial and/or insurance claim information. This information may be released to:

information may ONLY BE RELEASED TO ME.

Patient/Parent/Guardian Signature

Date:

Relationship to patient (if minor)

New Patient Form

Patient Information

Responsible Party Information

Dental Insurance Information

Subscriber #1

Medical History

Dental History

Female Patients only:

BENEFITS

PRIVACY NOTICE

PATIENT ACKNOWLEDGMENT

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION