ABOUT YOU
Today's Date:
Name:
Last Name
First Name
Title
I prefer to be called:
MALE
FEMALE
Birthdate:
Age:
SS#:
Home Address:
Street
City
State
ZIP
Marital Status:
Single
Married
Divorced
Widowed
Separated
Home Phone:
Work Phone:
Email Address:
Employer:
Employer's Address:
Street
City
State
ZIP
Occupation:
Where and when are the best times to reach you?:
Whom may we thank for referring you?:
Other family members seen by us:
General Dentist:
Last Visit Date:
SPOUSE INFORMATION
Name:
Last Name
First Name
Title
Employer:
Work Phone:
Birthdate:
SS#:
Person Responsible for Account:
Work Phone:
Home Phone:
Billing Address:
Street
City
State
ZIP
Relation:
SS#:
Employer:
ORTHODONTIC INSURANCE
PRIMARY
Orthodontic Coverage:
YES
NO
Dental Insurance Company Name:
Insurance Company Address:
Insurance Company Phone #:
Group Number (Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's SS# or Subscriber's ID#:
Insured's Employer:
SECONDARY
Orthodontic Coverage:
YES
NO
Dental Insurance Company Name:
Insurance Company Address:
Insurance Company Phone #:
Group Number (Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's SS# or Subscriber's ID#:
Insured's Employer:
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Relation:
Work Phone:
Home Phone:
MEDICAL & DENTAL HISTORY
What are the main concerns that you would like orthodontics to address?
Have you ever been evaluated for orthodontic treatment?:
YES
NO
Have you ever had orthodontic treatment?:
YES
NO
If yes, where and when:
Have you ever had an injury to your:
MOUTH
TEETH
CHIN
If yes, explain:
Have adenoids been removed?
YES
NO
Have tonsils been removed?
YES
NO
Have you been informed of any missing or extra permanent teeth?
YES
NO
Have you ever been advised by your physician to take an antibiotic prior to dental procedures?
YES
NO
If yes, explain:
Is there or has there been a concern about periodontal (gum and bone) problems?:
YES
NO
Is there any UNUSUAL dental history?:
YES
NO
If yes, please explain:
Do you have a tendency to gag easily?:
YES
NO
Are you frightened or anxious about orthodontic treatment?:
YES
NO
Are you concerned about the appearance of your teeth?
YES
NO
Which aspects of orthodontic treatment are you most concerned about?
Quality
Cost
Discomfort
Length of treatment
Do any speech problems exist:
YES
NO
Do you have any of the following habits?
Clenching/Grinding Teeth:
CURRENT
PREVIOUS
NEVER
When Stopped
Lip Sucking/Biting:
CURRENT
PREVIOUS
NEVER
When Stopped
Mouth Breather:
CURRENT
PREVIOUS
NEVER
When Stopped
Nail Biting:
CURRENT
PREVIOUS
NEVER
When Stopped
Thumb Sucking:
CURRENT
PREVIOUS
NEVER
When Stopped
Finger Sucking:
CURRENT
PREVIOUS
NEVER
When Stopped
Tongue Thrust:
CURRENT
PREVIOUS
NEVER
When Stopped
Snoring:
CURRENT
PREVIOUS
NEVER
When Stopped
Smoking:
CURRENT
PREVIOUS
NEVER
When Stopped
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding:
YES
NO
ADHD:
YES
NO
Any Hospital Stays:
YES
NO
Any Operations:
YES
NO
Artificial Bone/Joint:
YES
NO
Artificial Heart Valve/Pacemaker:
YES
NO
Arthritis:
YES
NO
Asthma:
YES
NO
Cancer/Chemotherapy:
YES
NO
Cleft Lip:
YES
NO
Repaired?
YES
NO
Cleft Palate:
YES
NO
Repaired?
YES
NO
Diabetes:
YES
NO
Difficulty Breathing:
YES
NO
Emotional Problems:
YES
NO
Emphysema:
YES
NO
Fainting/Dizziness:
YES
NO
Genetic Disorders:
YES
NO
Glandular Disorders:
YES
NO
Glaucoma:
YES
NO
Handicaps/Disabilities:
YES
NO
Hearing Impairment:
YES
NO
Heart Attack/Stroke:
YES
NO
Heart Murmur:
YES
NO
Heart Trouble:
YES
NO
Hemophilia:
YES
NO
Hepatitis:
YES
NO
High/Low Blood Pressure:
YES
NO
HIV+/AIDS:
YES
NO
Kidney/Liver Problems:
YES
NO
Mitral Valve Prolapse:
YES
NO
Rheumatic/Scarlet Fever:
YES
NO
Seizures/Epilepsy:
YES
NO
Sleep Disorders:
YES
NO
Tourette Syndrome:
YES
NO
Tuberculosis:
YES
NO
Tumors:
YES
NO
Woman: Pregnant?
YES
NO
# of weeks
Please describe any medical problems that you have had:
Physician:
Phone #:
Date of last visit:
Are you currently under the care of a physician?:
YES
NO
Do you have more than a normal tendency toward having a cold, ear infection or sore throat?:
YES
NO
Please describe your current physical health:
GOOD
FAIR
POOR
Are you taking any prescription/over-the-counter drugs?:
YES
NO
If yes, please explain.
Please describe your current dental health:
GOOD
FAIR
POOR
Have you ever taken any prescribed diet medications?
YES
NO
Are you allergic to any of the following:
Aspirin:
YES
NO
Any Metal:
YES
NO
Any Plastic:
YES
NO
Codeine:
YES
NO
Dental Anesthetics:
YES
NO
Erythromycin:
YES
NO
Latex:
YES
NO
Penicillin:
YES
NO
Tetracycline:
YES
NO
Other:
YES
NO
Please list any other drug you are allergic to:
Have you ever had any of the following issues?
Have you ever had any pain/tenderness in your jaw joint (TMJ/TMD):
YES
NO
Headaches:
YES
NO
Jaw Clicking/Popping:
YES
NO
Jaw Soreness:
YES
NO
Jaw Stiffness/Locking:
YES
NO
SIGNATURE
I, the undersigned, have completed the health history questionnaire and certify that the preceding information is true and correct. This office will not be held responsible for any problems arising out of inadequate information not disclosed. I grant authority to Keesler Orthodontics to perform all procedures and treatments in the patient’s best interest. I have been informed of Keesler Orthodontics Notice of Privacy Practices.
Signature
Date 11/21/2008
SIGNATURE ON FILE
I authorize the doctor named above to use my name on any and all claims or documents that relate to health insurance benefits due to me and my dependents.
I authorize release or any information related to any claims to all my insurance companies or other relevant parties.
I understand that I am responsible for my bill and agree to pay all charges for services and items provided to me.
I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies.
I authorize payment of health benefits otherwise payable to me, directly to my doctor.
I permit a copy of this authorization to be used in place of the original.
This "Signature on File" is valid for one year from the date indicated below.
Signature of Beneficiary.
Guardian or Personal Representative:
Date: 11/21/2008
Relationship to Beneficiary:
THANK YOU FOR FILLING OUT THIS FORM COMPLETELY
I have read and understand that this notice describes how medical information may be used and disclosed. I also understand that this notice may be changed from time to time to make the revised notice effective for all protected health information.
Signature
:
Date
: 11/21/2008
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Privacy Policy