Pairorthodontics calabasas adult health history form

Has there been any injuries to the face, mouth or teeth?

Yes No

Do you have any speech problems?

Yes No

Have you had tongue-thrust or speech therapy?

Yes No

Have you ever been informed of any missing or extra teeth?

Yes No

Have you ever been told you have TMJ (Temporomandibular Joint) problems?

Yes No

Does your jaw joint ever make noise (cracking or popping sounds) when chewing or yawning?

Yes No

Has your jaw ever locked open?

Yes No

When was the last dental care?

Interests ie. Sports, hobbies, etc.

WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH:

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in strictest of confidence, and it is my responsibility to inform this office of any changes in my health status.

Calabasas

ORTHODONTICS ACQUAINTANCE CARD

IF YOU HAVE ORTHODONTICS INSURANCE, PLEASE COMPLETE INFORMATION BELOW:

DENTAL INSURANCE COMPANY #1

DENTAL INSURANCE COMPANY #2

DENTAL/MEDICAL HISTORY

PLEASE CHECK:

ARE YOU ALLERGIC TO ANY MEDICATIONS

DO YOU NEED TO BE PREMEDICATED BEFORE DENTAL TREATMENT?

PLEASE CHECK:

WHAT DO YOU WANT ORTHODONTICS TREATMENT TO ACCOMPLISH: