Please complete all applicable biographical, financial, health, dental and sleep sections below. Please be sure to sign the Notice of Privacy Practices. Thank you and we look forward to meeting you and starting your orthodontic journey!
Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patient's main orthodontic concern?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Apprehensive about dental care?
No
Yes
Brush teeth daily?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Frequently chew gum?
No
Yes
Frequent headaches?
No
Yes
Frequent sore throats?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Neck or shoulder pain?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Requires premedication?
No
Yes
Snores during sleep?
No
Yes
Speech problems or therapy?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anemia or blood disorder?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Diabetes?
No
Yes
Emotional problems treatment?
No
Yes
Endocrine problems?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Ever been hospitalized?
No
Yes
Kidney disease?
No
Yes
Latex or Metal Allergy?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Nervous disorders?
No
Yes
Pneumonia?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Radiation treatment?
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
No
Yes
If patient is a girl, has menstruation begun?
No
Yes
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Children only: Pediatric Sleep Questionnaire
While sleeping does your child...
snore more than half the time?
No
Yes
always snore?
No
Yes
snore loudly?
No
Yes
Have 'heavy' or loud breathing?
No
Yes
have trouble breathing, or struggle to breathe?
No
Yes
Have you ever...
seen your child stop breathing during the night?
No
Yes
Does your child...
tend to breathe through the mouth during the day?
No
Yes
have a dry mouth on waking up in the morning?
No
Yes
occasionally wet the bed?
No
Yes
wake up feeling unrefreshed in the morning?
No
Yes
have a problem with sleepiness during the day?
No
Yes
Has a teacher or other supervisor commented that your child appears sleepy during the day?
No
Yes
Is it hard to wake your child up in the morning?
No
Yes
Does your child wake up with headaches in the morning?
No
Yes
Did your child stop growing at a normal rate at any time since birth?
No
Yes
Is your child overweight?
No
Yes
This child often...
does not seem to listen when spoken to directly?
No
Yes
has difficulty organizing task and activities?
No
Yes
is easily distracted by extraneous stimuli?
No
Yes
fidgets with hands or feet or squirms in seat?
No
Yes
is 'on the go' or often acts as if 'driven by a motor'?
No
Yes
interrupts or intrudes on others (e.g. butts into conversations or games)?
No
Yes
Total number of 'Yes' responses:
Adults Only: STOP-BANG Adult Sleep Apnea Screening Questionnaire
Snoring?
Do you
Snore Loudly
(loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
No
Yes
Tired?
Do you often feel
Tired, Fatigued, or Sleepy
during the daytime (such as falling asleep during driving or talking to someone)?
No
Yes
Observed?
Has anyone
Observed
you
Stop Breathing
or
Choking/Gasping
during your sleep?
No
Yes
Pressure?
Do you have or are being treated for
High Blood Pressure
?
No
Yes
Body Mass Index more than 35 kg/㎡?
Height:
Weight:
Age older than 50?
No
Yes
Neck Size Large? (Measured around Adams apple)
For male, is your shirt collar 17 inches / 43cm or larger? For female, is your shirt collar 16 inches / 41cm or larger?
No
Yes
Gender = Male?
No
Yes
Notice of Privacy Practices
I have reviewed a copy of the Westwalk Orthodontic Group Notice of Privacy Practices.
Click here to review
Signature:
Date: