Patient Information
Salutation
*
Mr.
Mrs.
Ms
Dr.
Other
Patient's First & Last Name
*
Home Address
*
City
*
Postal Code
*
Email Address
*
Birthday
*
Home Phone
*
Patient's Cell
*
Gender
*
Male
Female
Are you currently pregnant
*
Yes
No
Do you have any children or relatives who have had treatment in this practice?
*
Yes
No
Employer's Name
*
Occupation
*
Name of Spouse
*
Physician
*
Dentist
*
How were you referred to our practice?
*
Insurance
Do you have dental insurance that covers orthodontic treatment?
*
Yes
No
If yes, please provide more details below. If no, please enter N/A in the fields below.
Primary Subscriber Name
*
Primary Subscriber Birthdate
*
Primary Insurance Carrier
*
Primary Group Number
*
Primary ID Number
*
Primary Reimburses at %
*
Primary Maximum
*
Secondary Subscriber Name
*
Secondary Subscriber Birthdate
*
Secondary Insurance Carrier
*
Secondary Group Number
*
Secondary ID Number
*
Secondary Reimburses at %
*
Secondary Maximum
*
Patient History
Are you in perfect health?
*
Yes
No
If no, please specify
*
Have you previously consulted another orthodontist?
*
Yes
No
Have you had any previous orthodontic treatment?
*
Yes
No
Do you want orthodontic treatment?
*
Yes
No
Indifferent
Are you under the care of a physician for any reason?
*
Yes
No
Are you currently taking any medication?
*
Yes
No
If yes, please list
*
Are you in a high risk group for HIV Infection?
*
Yes
No
Allergies
*
Yes
No
Do you have a history of any serious illness?
*
Yes
No
Have you had injuries to the head?
*
Yes
No
Have you been informed of any missing or extra teeth?
*
Yes
No
Do you have a history of any of the following? Check all that apply
*
Diabetes
Epilepsy
Heart Trouble
Gland or Endocrine Problems
Rheumatic Fever
Fainting or Dizziness
Bone Disorders
Nervous Disorders
Congenital Abnormalities
Emotional Disorders
Tuberculosis
Liver Problems
Blood Disorders
Hepatitis
Anemia
HIV Infection
Prolonged Bleeding
Kidney Problems
Frequent Colds
Asthma
Ear Infections
Chronic Nasal Obstruction
Mouthbreathing
Adenoid Problems
Tonsillitis
Tongue thrusting
Tooth grinding or clenching
Headaches (frequent)
Muscular soreness around head and neck
Jaw joint clicking of popping
Thumbsucking
Finger sucking
Lip biting or sucking
N/A
Have you received treatment for any of the above problems?
*
Yes
No
Have your tonsils been removed?
*
Yes
No
Have your adenoids been removed?
*
Yes
No
Do you have regular dental checkups?
*
Yes
No
Date of Last Checkup
*
Tooth Brushing
*
After every meal
Once per day
Twice per day
Do you floss?
*
Yes
No
Reason for seeking orthodontic consultation?
*
In accordance with Canada's federal anti-spam regulations, I accept to be contacted through email by South Surrey Smiles
*
Yes
No
I hereby acknowledge that the health history provided is correct.
*
Yes my information is correct
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