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Patient form - ng

Dr. Julia Ng
Patient name:_________________________ Birthdate:________________________ Home Address:_____________________________ Age:_________ Gender: ( )M City:_________________________ Postal code:______________________ Home Phone:____________________ Email:_________________________________ Name of parent or guardian (for patients under 19 yrs):____________________ Place of Employment:_______________________ Work phone:_______________ Person responsible for the account:_______________________________________ Referred by:_____________________________ Dentist:________________________ Do you have a dental plan with orthodontic coverage? ( )Yes _________________________________________________________________ If so, please complete the fol owing: Name of employer: _____________________________________________________ Name of insurance co:___________________________________________________ Group, plan, or policy no:________________________________________________ ID # or S.I.N.:_________________________________ Dependent #:_____________ Name of subscriber:_________________________ Birthdate:__________________ Name of employer: ____________________________________________________ Name of insurance co:___________________________________________________ Group, plan, or policy no:________________________________________________ ID # or S.I.N.:_________________________________ Dependent #:_____________ Name of subscriber:_________________________ Birthdate:__________________ I authorize Dr. _________________ to perform a complete orthodontic examination. Signature:___________________________________ Date:______________________ Clinical Interview
Patient name:________________________ Date:_________________________
Date of birth:________________________
Form completed by:___________________________
Name of physician:____________________________
Chief Complaint

Inherited and Congenital
Yes
Were there congenital anomalies present at birth (cleft lip/palate, etc)? Is there anyone else in the family who has a similar dental condition? Do you have siblings? __________________________ Have they (siblings) had treatment? _________________
Environmental
Yes
Is there any history of asthma, hay fever, allergies? Have the tonsils and adenoids been removed? Were there any major falls, accidents, or operations to the head region?
Dental History
Yes
Have any primary (baby) or permanent (adult) teeth been removed? Have you had any previous orthodontic treatment? _____________ Have there been any accidents, falls, or blows to the teeth?
What dental treatments have you had in the past? Any root canals?
_________________________________________________________________
Most recent dental check-up?__________________________________________
History of Habits
Yes
Other mouth habits________________________ Started____________ Stopped_____________ How often____________
Patient Attitude
Yes
Would you wear braces for several years? Would you cooperate by brushing, avoiding certain foods, and if needed, wearing elastics or other appliances? Yes Do you have activities that may interfere with appointments? Do you have difficulty or pain or both when opening your mouth (eg:yawn)? Does your jaw get “stuck”,”locked” or “go out”? Do you have difficulty/pain/both when chewing, talking, or using your jaws? Are you aware of noises in the jaw joints? Does your bite feel uncomfortable or unusual? Have you had a recent injury to your head, neck or jaw? Have you previously been treated for a jaw joint problem?
Medical History
Yes
Are you taking any medication or drugs at the present time?____________ Have you ever had any serious illness such as (please circle): Abnormal blood pressure Other (please specify)________________________________________________ Yes Do you require antibiotics before you have dental work done? Are you allergic to any foods or medication? If so, please list. Have you ever taken oral bisphosphonate medication? (Fosomax, Actonel,

Source: http://www.refineorthodontics.ca/docs/patient-form-ng.pdf

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