Welcome to our office. The following information is requested to enable us to provide you with an accurate orthodontic evaluation during your initial examination. In order for us to thoroughly diagnose any condition, we must have accurate background and health information. This information is confidential and will be used responsibly as per our privacy protocol.
Date: ______________________________ Patient (Please Print or Type Directly) Name: ______________________________________ Sex Female Male
Birth date: ___________________Age:_______
Address: ________________________________________________________________________________________________ Home Tel: __________________________Cell: _________________________Business #:___________________Ext:________ Email: __________________________________________________________ Appointment Email Reminders Yes
School:______________________________________Grade:___ Patient Lives With: ___________________________________
Dentist: ________________________ Physician: _______________________ Orthodontic Insurance Yes
Person responsible for account if different from above Name: _______________________________________ Relationship (to patient): ______________________________________ Address: ________________________________________________________________________________________________ Home Tel: __________________________Cell: _________________________Business #:______________________ext: _____
Email: __________________________________________________________ Appointment Email Reminders Yes
Other Responsible Party ( if different from above) Name: _______________________________________ Relationship (to patient): ______________________________________
Address: ________________________________________________________________________________________________ Home Tel: __________________________Cell: _________________________Business #:______________________ext: _____
Email: __________________________________________________________ Appointment Email Reminders Yes
Whom may we thank for referring you to our office?
Name: _____________________Friend Name: ___________________ Dentist Name: _____________________
Names of other family members who have been seen at our office: __________________________________________________
In order to provide the best possible care for our patients, we would appreciate your accurate completion of the following questionnaire.
Yes No Medical History ____ ____ Is the patient in good general health? When was the last medical check-up or visit to a physician? What was the reason for this visit? ______________________________________________________ ____ ____ Has there been a change in general health in the past year? ____ ____ Is there currently treatment ongoing for any medical condition or has treatment been provided
in the last year? Please provide reason: ___________________________________________________
____ ____ Is there a history of having been hospitalized for any serious conditions or operations? Please specify: ______________________________________________________________________ ____ ____ Is there currently a need for medications or non prescription drugs of any kind? If yes, please specify: ___________________________________________________________________________________ ____ ____ Allergies or drug sensitivities: __________________________________________________________ Yes No ____ ____ Have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid
or Zometa? _________________________________________________________________________ ____ ____ Any developmental, hereditary or behavioural concerns? _____________________________________ ____ ____ For women only – are you pregnant? And if so, when is the expected delivery date? _______________ Have you ever had or been treated for (Please Circle):
Cancer Rheunmatic fever Blood Pressure Thyroid disorder Anemia HIV/A.I.D.S
Asthma Stomach Disorder Heart trouble Headaches Epilepsy Other S.T.D’s Sinusitis Liver Disease Joint problems Kidney Disease Hay Fever Adenoids/Tonsils
____ ____ Is there anything else we should know about your medical history? _____________________________ ___________________________________________________________________________________
___________________________________________________________________________________
Yes No Dental History ____ ____ When was your last dental visit? ________________________________________________________ ____ ____ Do you regularly brush your teeth? ____ ____ Do you regularly floss your teeth? ____ ____ Do you see a dentist regularly? ____ ____ Do any of your teeth ache? ____ ____ Have you ever been advised to take antibiotics before dental appointments? ____ ____ Do your gums bleed when brushing? ____ ____ Do you have any pain when chewing? ____ ____ Do you have any TMJ symptoms? (i.e. clicking, pain, popping) in the jaw joint? Yes No Orthodontic What are you hoping to accomplish with orthodontic treatment? _______________________________
__________________________________________________________________________________
____ ____ Is there a history in your family of irregular or missing teeth? ____ ____ Have you or other family members had orthodontic treatment? ____ ____ Is the orthodontic problem obvious to the patient? ____ ____ Is the patient satisfied with the appearance of their teeth? ____ ____ Has there been a finger or thumb sucking habit - ongoing/in the past? ____ ____ Has there been any accidents involving the teeth/jaw/nose? ____ ____ Has the patient had any teeth extracted by the dentist? ____ ____ Have there been any previous orthodontic consultations?
Any orthodontic fears or concerns? _______________________________________________ ___________________________________________________________________________________
As a part of Canada’s PIPEDA (Personal Information Protection and Electronic Document Act) Bozek Orthodontics complies with National and Provincial privacy legislation, the standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Privacy of your personal information is an important part of our office policies. We are committed to collecting, using and disclosing you personal information responsibly and you may ask at anytime to see our privacy protocol and speak to our privacy officer.
Permission Granted _________________________________________________ (PARENT/GUARDIAN SIGNATURE)
To the best of my knowledge, The above information is correct: ______________________________________ __________________________________ (SIGNATURE) (DATE
PHD6™ SPECIFICATIONS Six-Gas Detector Material Weight (Alkaline) Weight (Alkaline) + Pump Weight (Lithium-Ion) Weight (Lithium-Ion) + Pump Dimensions w/o std belt clip 6.63 x 3.13 x 2 in./16.83 x 7.94 x 5.08 cm Dimensions with std belt clip 6.63 x 3.13 x 2.5 in./16.83 x 7.94 x 6.35 cm Dimensions w/o std belt clip, with pump 8.5 x 3.13 x 2.38 in./21.59 x
Welcome to our office. The following information is requested to enable us to provide you with an accurate orthodontic evaluation during your initial examination. In order for us to thoroughly diagnose any condition, we must have accurate background and health information. This information is confidential and will be used responsibly as per our privacy protocol.
Date: ______________________________