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Confidential Adult Patient Health History & Information

Patient Information
Gender
Insurance Information
Policy Holder
Do You Have Dual Coverage?
If yes, please fill out the following
Policy Holder
Responsible Party Information
Name of person financially responsible for account:
Do you have dental insurance which covers orthodontics?
Correspondence should be sent to:
Dental History
What do you consider the main benefits of orthodontic treatment?
Cosmetic

Functional

Psychological/Emotional

Other

Have you ever had an orthodontic consultation:
Are you interested in
Frequency of dental check-ups
Answer yes if applicable now or in the past:
Apprehensive about dental care

Discomfort from teeth

Previous orthodontic therapy

Teeth that are shifting

Frequent canker sores

Thumb/finger sucking as a child

Fluoride treatments

Any injuries to face, mouth, teeth

Speech therapy

Injury involving teeth

Injury to either jaw

Frequent clenching of teeth

Grinding of teeth

Wake up with sore teeth

Wake up with sore jaw

Jaw joint sounds

Jaw joint pain

Jaw tires when eating

Jaw catches when opening

Jaw locks in closed position

Jaw locks in open position

Facial pain

Frequent headaches

Neck or shoulder pain

Tonsils/Adenoids removed

Any missing permanent teeth

Any discomfort from gums

Requires premedication

Medical History
Are you currently in good physical health?
Answer yes if applicable now or in the past:
Allergic to latex

Allergic to metals

Anemia/Radiation treatment

Arthritis

Asthma

Congenital heart defect

Diabetes

Ever been hospitalized

Heart attack/Stroke

Heart murmur

Hepatitis

Hormone therapy

Mouth breathing

Prolonged bleeding

Psychological counseling

Rheumatic fever

Seizures/Epilepsy

Taking medications

Tuberculosis

Drug allergies

Requires premedication

 

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Office Locations

ORLAND PARK
15100 S. LaGrange Rd.,
Orland Park, Illinois 60462
ph. 708.349.1740
OAK FOREST
5950 W. 159th St.,
Oak Forest, Illinois 60452
ph. 708.687.4280