PATIENT INFORMATION

PATIENT NAME:

SEX ASSIGNED AT BIRTH:

Male Female

GENDER IDENTITY:

Male Female Non-Binary Other

Specify:

PREFERRED PRONOUNS:

He/him/his She/her/hers They/them/theirs

BIRTHDATE:

AGE:

ADDRESS:

POSTAL CODE:

HOME PHONE:

MOTHERS NAME:

EMAIL:

OCCUPATION:

EMPLOYER:

WORK PHONE:

CELL PHONE:

FATHERS NAME:

EMAIL:

OCCUPATION:

EMPLOYER:

WORK PHONE:

CELL PHONE:

FOR VIRTUAL APPOINTMENTS:

iPhone

Other

Cell (Facetime):

Email (Zoom):

SIBLINGS:

DENTIST NAME:

REFERRAL SOURCE:

DO YOU HAVE DENTAL INSURANCE COVERING ORTHODONTICS?

YES NO

PLEASE NOTE:

Regular visits to your dentist must continue during orthodontic treatment
Some appointments will infringe on school time or work

MAIN CONCERN/REASON FOR ORTHODONTIC CONSULTATION:

HAVE YOU OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:

Rheumatic Fever:

Yes No

Diabetes:

Yes No

Chronic kidney problems:

Yes No

Lung problems:

Yes No

Epilepsy:

Yes No

Prolonged bleeding:

Yes No

Heart problems:

Yes No

Liver problems:

Yes No

Do you have any allergies?

Yes No

If yes, to what?

Do you have any condition that could affect your immune system (e.g. AIDS, HIV, or Leukemia?)

Yes No

If yes, please describe your condition:

Do you have any medical problems?

Yes No

If yes, what is your problem?

Do you take any medication?

Yes No

If yes, what medication?

When was your last dental checkup and cleaning?

Do you have any of the following habits?

Thumb/sooth sucking

Yes No

Nail biting

Yes No

Grinding teeth at night?

Yes No

Mouth breathing?

Yes No

Snoring?

Yes No

Has any member of the family had any orthodontic treatment?

Yes No

Have you had any previous orthodontic consults or treatment?

Yes No

Do you play any musical instruments?

Yes No

If yes, what?

I give permission to allow Drs. D. Sonya and J. Nagamatsu to report any findings to my dentist or any other dental professional as they deem necessary. I also give permission for any records made in the process of examination, treatment and retention to be used for purposes of research, education or publication in professional journals.

Name:

Select one:

Mother Father Patient Guardian

Date

Your information will be encrypted.

PATIENT INFORMATION - CHILD