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consultation questionaire

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

Source: http://www.bozekorthodontics.com/Portals/0/CONSULTATIONQUESTIONAIRE1.pdf

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