Confidential Patient Information
First Name:
Last Name:
Name Patient Goes by:
Birthdate:
Gender:
Male
Female
Other
Email:
Address:
City:
State:
Zip:
Preferred Contact #:
Patient's Dentist:
Last Dental Visit:
School:
Whom may we thank for referring you to our practice?
Reason for seeking Orthodontic treatment:
Have you or anyone in the family had Orthodontics in the past?
No
Yes
Please list:
Relationship to Patient
When treated:
What was treated Orthodontically?
Relationship to Patient:
When treated:
What was treated Orthodontically?
Relationship to Patient:
When treated:
What was treated Orthodontically?
Family Information
Responsible Party #1
First Name:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Address:
City:
State:
Zip:
Preferred Contact #:
Email:
Employer:
Occupation:
Responsible Party #2
First Name:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Address:
City:
State:
Zip:
Preferred Contact #:
Email:
Employer:
Occupation:
Names and ages of other children in the family:
Insurance Information
Do you have dental insurance?
No
Yes
Does it cover orthodontics?
No
Yes
Primary Insurance
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Policy Holder's Birthdate:
Policy Holder's Employer:
Subscriber ID:
Group Number:
Social Security #:
Do you have secondary insurance? If so, please fill in information below.
No
Yes
Secondary Insurance
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Policy Holder's Birthdate:
Policy Holder's Employer:
Subscriber ID:
Group Number:
Social Security #:
Medical History
Do you have or have you ever been treated for any of the following? Cannot be blank.
Sleep Apnea?
No
Yes
Asthma?
No
Yes
HIV/AIDS?
No
Yes
Fainting or Dizziness?
No
Yes
Heart disease (incl. high BP) or Stroke?
No
Yes
Nervous Disorders?
No
Yes
ADD/ADHD?
No
Yes
Sensory Sensitivity
No
Yes
Rheumatic Fever?
No
Yes
Epilepsy?
No
Yes
Bone Disorders?
No
Yes
Kidney Disease?
No
Yes
Cancer or Tumor?
No
Yes
Glaucoma?
No
Yes
Eating Disorders, Bulimia, Anorexia?
No
Yes
Diabetes?
No
Yes
Endocrine Problems?
No
Yes
Frequent Colds?
No
Yes
Frequent Sore Throats?
No
Yes
Frequent Ear Infections?
No
Yes
Have there been any injuries to face, mouth, or teeth in the past 6 months?
No
Yes
Any history of thumb, digit, or pen sucking within the past year?
No
Yes
Any history of nail, lip, cheek, or tongue biting within the past year?
No
Yes
Any history of clenching or grinding teeth?
No
Daytime
Nighttime
Both_Daytime_And_Nighttime
Any history of speech problems or speech therapy?
No
Yes
Has the patient reached puberty?
No
Yes
Have tonsils and/or adenoids been removed?
No
Yes
If so, when?
Family history of an underbite?
No
Yes
Family history of jaw surgery?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Please list any drug allergies or sensitivities:
Are there any other dental/medical issues or details that you think we should be aware of?
For Patients 18 and under
Pediatric Airway Health
is crucial for our children’s growth and development.
Sleep Related Breathing Disorders (SRBD)
are disorders characterized by disruptions in normal breathing patterns. SRBDs are potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms. Common SRBDs include snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA). OSA has been associated with metabolic, cardiovascular, respiratory and dental and other diseases.
In children, undiagnosed and or untreated OSA can be associated with cardiovascular problems, impaired growth, as well as learning and behavioral problems.
While sleeping does your child:
Snore?
No
Sometimes
All the time
Don't Know
Snore loudly?
No
Yes
Don't Know
Have "heavy" or "loud" breathing?
No
Yes
Don't Know
Have trouble breathing or struggle to breathe?
No
Yes
Don't Know
Have you ever:
Seen your child stop breathing during the night?
No
Yes
Don't Know
Does your child:
Tend to breathe through the mouth during the day?
No
Yes
Don't Know
Have a dry mouth on waking in the morning?
No
Yes
Don't Know
Occasionally wet the bed?
No
Yes
Don't Know
Does your child:
Wake up feeling unrefreshed in the morning?
No
Yes
Don't Know
Have problems with sleepiness during the day?
No
Yes
Don't Know
Has a teacher or other supervisor commented that your child appears sleepy during the day?
No
Yes
Don't Know
Is it hard to wake your child in the morning?
No
Yes
Don't Know
Does your child wake up with headaches in the morning?
No
Yes
Don't Know
Did your child ever stop growing at a normal rate?
No
Yes
Don't Know
This child often:
Does not seem to listen when spoken to directly
No
Yes
Don't Know
Has difficulty organizing tasks and activities
No
Yes
Don't Know
Fidgets with hands or feet or squirms in seat
No
Yes
Don't Know
Is "on the go" or often acts as if "driven by a motor"
No
Yes
Don't Know
Interrupts or often intrudes on others (in conversation or in games)
No
Yes
Don't Know
Photo and Records Release
I, the undersigned, do hereby request and give my permission to Deepa Vyas, D.M.D. and Vyas Orthodontics to provide other health care providers and insurance companies any and all information with respect to my dental care. Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, xrays, models and copies of all dental and medical records.
I, the undersigned, do hereby relinquish any and all rights to photographs, portraits, prints, or other photographic reproductions captured with still, motion picture, video, digital or other cameras for use by Deepa Vyas, D.M.D. and Vyas Orthodontics. Unless images are used to communicate with another care provider, no names, birthdates or identifiable information will be linked to any image.
Parent or Guardian E-Signature:
Acknowledgment of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Vyas Orthodontics. The Statement of Privacy Practices describes that types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility and on the office website.
Vyas Orthodontics reserves the right to change the privacy practices currently describes in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.
Additional Disclosures Authorization
In addition to the allowable disclosure described in the Statement of Privacy Practices. I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is “NO”. Without indicating “YES” in answer to each individual question, personal protected information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
Parent(s) only:
No
Yes
Any member of the immediate family: (Parent(s), Brother, Sister)
No
Yes
Any member of my extended family: (Grandparent(s), Aunt(s), Uncle(s), etc.)
No
Yes
Other:
Parent's or Guardian's E-Signature: