Keith J. Kohrs, DDS, PC

Specialist in Orthodontics

ADULT HEALTH HISTORY

Patient Information

First Name:
Middle Initial:
Last Name:
Prefers to be called:
Address:
City:
State:
Zip:
How long at this address?
Previous address?
Cell Phone:
Home or Work Phone:
Email Address:
Gender:
Age:
Birthdate:
Marital Status:
Occupation:
Employer:
Years with Current Employer:
Emergency Contact:
Relationship to Patient:
Phone:
Spouse's Name:
Birthdate:
Spouse's Occupation:
Spouse's Employer:
Years with Current Employer:
Cell Phone:

General Information

Who may we thank for referring you to our practice?
General Dentist:
Last Dental Visit:
Next Dental Visit:
Other Dentists/Specialists now being seen:
Reason:
Please be specific: What are your concerns and what would you like to accomplish with orthodontics?
Who suggested that you might need orthodontic treatment?
Have you ever been evaluated for orthodontic treatment?
If so, when?
By whom?
How do you feel about braces?
How do you feel about Invisalign?

Financially Responsible and Dental Insurance Information

First Name:
Middle Initial:
Last Name:
Do you have an HSA (health savings account) or Flex account?
Is there a dental insurance company we can contact concerning orthodontic coverage?
Dental Insurance Company Name:
Group Number:
Address where claims are filed:
Phone for Providers:
Primary Policy Holder's Name:
ID/SS#:
Date of Birth:
Dual insurance info, if applicable:

Medical and Dental History

Your answers are for office records only, and are confidential. A thorough medical history is essential to complete an orthodontic evaluation. For the following questions, please mark yes, no, or don't know/understand. Now or in the past, have you had or been treated for:

MEDICAL

Birth defects or hereditary problems?
Bone fractures, or major injuries?
Injury to face, head, or neck?
Arthritis or joint problems?
Cancer, tumor, radiation, or chemotherapy?
Diabetes or low blood sugar?
Kidney problems?
AIDS or HIV positive?
Immune system problems?
Treatment of osteoporosis?
Hepatitis, jaundice, or other liver problems?
Seizures, fainting spells, or neurological problems?
Mental health disturbance or depression?
Eating disorders (anorexia, bulimia)?
Frequent migraines or headaches?
High or low blood pressure?
Heart defects?
Vision, hearing, or speech problems?
ADD/ADHD?

DENTAL

Permanent or extra teeth removed?
Extra or missing teeth?
Chipped or injured permanent teeth?
Food impaction between the teeth?
Sensitive or sore teeth?
Jaw fractures, cysts, or infections?
Frequent oral habits (thumb sucking, pen chewing)?
History of speech problems or therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Trouble associated with previous dental treatment?
Gum disease?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking of jaw joint(s)?
Soreness of jaw muscles or face muscles?
Diagnosis or treatment for TMJ or TMD?
Sleep Apnea?
Latex sensitivity?
Other conditions/diseases not listed:
Allergies:
Medications you currently take:
Have you ever taken any medications to strengthen your bones? If yes, please list the medication(s):
Please elaborate on any dental or orthodontic concerns and any additional medical concerns:
FEMALES: Are You Pregnant?
E-Signature:
Date: