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Patient registration form

 

PATIENT INFORMATION

LAST NAME:
FIRST NAME:
NICKNAME:
FEMALE:

MALE:
BIRTH DATE:

(YEAR/MONTH/DAY)
ZIP CODE:
CITY:
STREET:
HOME PHONE:
OCCUPATION:
E-MAIL:
MOBILE:
BUSINESS PHONE:
WHO RECOMMENDING US?
NAME OF DENTIST:
DATE OF LAST VISIT:
MOTHER'S NAME:
HUNGARIAN SOCIAL INSURANCE NO.:
HEALTH INSURANCE PROVIDER AND NO.:

PARENT INFORMATION FOR CHILDREN

FATHER'S NAME: 

ADDRESS (IF DIFFERENT FROM PATIENT'S):
ZIP:

CITY:

STREET:

HOME PHONE:

WORK PHONE:

MOBILE:

HUNGARIAN SOCIAL INSURANCE NO.:

HEALTH INSURANCE PROVIDER AND NO.:

E-MAIL:

EMPLOYER:

EMPLOYER'S ADDRESS (ZIP):

EMPLOYER'S ADDRESS (CITY):

EMPLOYER'S ADDRESS (STREET):

MOTHER'S NAME: 

ADDRESS (IF DIFFERENT FROM PATIENT'S):
ZIP:

CITY:

STREET:

HOME PHONE:

BUSINESS PHONE:

MOBILE:

HUNGARIAN SOCIAL INSURANCE NO.:

HEALTH INSURANCE PROVIDER AND NO.:

E-MAIL:

EMPLOYER:

EMPLOYER'S ADDRESS (ZIP):

EMPLOYER'S ADDRESS (CITY):

EMPLOYER'S ADDRESS (STREET):

INFORMATION ABOUT PERSON FOR THIS ACCOUNT

NAME:
RELATIONSHIP:
EMPLOYED BY:
OCCUPATION:
ADDRESS (ZIP):
ADDRESS (CITY):
ADDRESS (STREET):
HOME PHONE:
BUSINESS PHONE:
MOBILE:
E-MAIL:
IF DIVORCE IS INVOLVED, WHO IS THE CUSTODIAL PARENT?
MAY PATIENT INFORMATION BE RELEASED TO THE NONCUSTODIAL PARENT?
YES:   NO: 

MEDICAL HISTORY

Please check if patient has or had?

YES:   NO:    Joint swelling?

YES:   NO:    Bone disorders?

YES:   NO:    Heart trouble?

YES:   NO:    Mitral Valve Prolapse?

YES:   NO:    Rheumatic trouble?

YES:   NO:    Thyroid problems?

YES:   NO:    Diabetes?

YES:   NO:    Emotional problems?

YES:   NO:    Brain injury?

YES:   NO:    Kidney or liver involvement?

YES:   NO:    Joint Prosthesis?

YES:   NO:    Anorexia/Bulimia?

YES:   NO:    AIDS/HIV infection?

YES:   NO:    Tuberculosis?

YES:   NO:    Anemia?

YES:   NO:    Epilepsy?

YES:   NO:    Prolonged bleeding?

YES:   NO:    Faintness/Dizziness?

YES:   NO:    Tonsils removed?

YES:   NO:    Adenoids removed?

YES:   NO:    Sore throats?

YES:   NO:    Tonsilitis?

YES:   NO:    Earaches?

YES:   NO:    Arthritis?

YES:   NO:    Orthopaedic problems?

YES:   NO:    Arch supporter?

YES:   NO:    Smoking?

YES:   NO:    Lip or chin implant?

YES:   NO:    Nose plastic surgery?


On items checked "Yes", please provide us with a more detailed description:

DENTAL HISTORY AND RELATED INFORMATION

YES:   NO:    Does patient visit dentist regularly?

YES:   NO:    Does patient visit hygienist regularly?

YES:   NO:    More than average amount of decay?

YES:   NO:    Any missing permanent teeth?

YES:   NO:    Any extra permanent teeth?

YES:   NO:    Any teeth removed by extraction?

YES:   NO:    Implant?

YES:   NO:    Restoration (crown, bridge, venners)?

YES:   NO:    Tooth bleaching recently?

YES:   NO:    Has an orthodontist been consulted previously?

YES:   NO:    Have you had braces before?

YES:   NO:    Do you wear retainer?

YES:   NO:    Contact figth sport?

YES:   NO:    Extreme sport?

YES:   NO:    Wind instrument?

YES:   NO:    Nail bite?

YES:   NO:    Piercing on lip, tounge?

YES:   NO:    Gingioplasty/Perio operation?

YES:   NO:    Is patient adopted?  At what age?: 

YES:   NO:    Any injuries to head  (face:   mouth:    teeth:  )

YES:   NO:   Thumb, finger lip sucking?    thumb:    finger:    lip: 


RESONS:

DENTAL HISTORY AND RELATED INFORMATION II.

APPROXIMATELY HOW MUCH HAS PATIENT GROWN IN THE LAST YEAR?

WHAT WOULD YOU LIKE TO HAVE ORTHODONTIC TREATMENT ACCOMPLISH (CHIEF COMPLAINT)?
HAVE YOU OR ANY MEMBER OF YOUR FAMILY OR CLOSE RELATIV HAD:
YES    NO: 
  RHEUMATOID ARTHITIS
YES    NO: 
   LUPUS
LIST ANY OTHER SERIUS ILLNESS OR OPERATIONS:

LIST ANY ALLERGIES (MENTHOL, METAL, LATEX, INJECTIONS, PLASTIC OR OTHER):

LIST DRUGS OR MEDICATIONS NOW BEING TAKEN:

IS PATIENTS PRESENTLY UNDER PHYSICIAN'S CARE?

NAME OF PHYSICIAN:

OTHER:

PATIENT'S ATTITUDE TOWARD ORTHODONTIC TREATMENT?
VERY MOTIVATED    WILL COPORATE IF NEEDED    NOT MOTIVATED   

ADOLESCENT FEMALES. HAS MENSTRUATION BEGUN?
YES   NO 

TDM SCREENING QUESTIONAIRE (OPTIONAL)
(Temporomandibular joint/jaw joint)

    Degree of discomfort
mild-1-2-3-4-5-severe
YES   NO  DO YOU SUFFER FROM FEQUENT HEADACHES?
YES   NO  DO YOU EVER HAVE PAIN, DISCOMFORT, OR OTHER SENSATIONS
(Ringing, roaring, stuffiness, etc. ) IN FRONT OF OR BEHIND THE EAR?
YES   NO  DO YOU EVER, HAVE PAIN, DISCOMFORT OR OTHER SENSATIONS (tiredness, pulling, weakness, burning, etc.) ABOUT THE EARS, TEMPLES, NECK OR CHEEK?
YES   NO  DOES IT EVER HURT TO CHEW, SWALLOW, IS YOUR BITE EVER UNCOMFORTABLE OR UNUSUAL?
YES   NO  DOES IT EVER HURT TO OPEN WIDE, TAKE A BIG BITE OR YAWN?
YES   NO  DOES YOUR JAW EVER MAKE NOISE (POPPING, CRACKING, GRATING, CLICKING, ETC) OR DOES YOUR JAW EVER LOCK? HAS IT EVER HAPPEND IN THE PAST?
YES   NO  HAVE YOU HAD ANY SERIUS TROUBLE ASSOCIATED WITH ANY PREVIOUS DENTAL TREATMENT? IF SO, EXPLAIN.
YES   NO  DO YOU KNOW, THAT YOU DO NOCTURAL OR DAYTIME BRUXISM OR TOOTH CLENCHING?
YES   NO  HAVE YOU PREVIOUSLY BEEN TREATED FOR JAW OR JOINT PROBLEMS?
YES   NO  ARE YOU WEARING REMOVABLE DENTAL APPLIANCES (e.g. bite plane, retainer, nightguard, etc)?
YES   NO  HAVE YOU HAD ACCIDENT TO THE HEAD, JAWS, NECK?
IF "YES":
REMARKS:

SMILE COSMETIC CONCERNS (OPTIONAL)
(self-analysis)

Why change your smile? Don't if you're happy with it, but ask yourself the folowing questions:

DOES YOUR SELF-CONFIDENCE LESSEN WHEN SMILING IN FRONT OF OTHER PEOPLE? YES   NO 
DO YOU EVER PUT YOUR HAND UP TO COVER YOUR SMILE? YES   NO 
DO YOU FEEL YOU PHOTOGRAPH BETTER FROM ONE SIDE OF YOUR FACE? YES   NO 
IS THERE SOMEONE YOU THINK HAS A BETTER SMLE THAN YOU? YES   NO 
DO YOU LOOK AT MAGAZINES AND WISH YOU HAD A SMILE AS PRETTY AS THE MODEL'S? YES   NO 
WHEN YOU READ A FASHION MAGAZINE, ARE YOUR EYES DRAWN TO THE MODEL'S SMILE? YES   NO 
WHEN YOU LOOK AT YOUR SMILE IN THE MIRROR, DO YOU SEE A MINOR DEFECT IN YOUR GUMS OR IN ANY OF YOUR TEETH? YES   NO 
DO YOU WISH YOUR TEETH WERE WHITER? YES   NO 
DO YOU WISH YOUR GUMS LOOKED BETTER? YES   NO 
DO YOU WISH YOU SHOWED MORE OR FEWER TEETH WHEN SMILING? YES   NO 
DO YOU THINK YOU SHOW TOO MUCH OR TOO LITTLE GUM TISSUE WHEN YOU SMILE AND SPEAK? YES   NO 
DO YOU WISH YOU HAD LONGER OR SHORTER TEETH? YES   NO 
WOULD YOU PREFER WIDER OR NARROWER TEETH? YES   NO 
ARE YOUR TEETH TOO SQUARE OR TOO ROUND? YES   NO 
DO YOU WISH YOUR TEETH WERE SHAPED DIFFERENTLY? YES   NO 
ARE YOU SATISFIED WITH YOUR PROFILE? YES   NO 
ARE YOU SATISFIED WITH THE NOSE PROJECTION AND SHAPE? YES   NO 
ARE YOU SATISFIED WITH YOUR CHIN? YES   NO 
ARE YOU SATISFIED WITH YOUR DENTAL MIDLINES? YES   NO 
DO YOU THINK YOUR UPPER TEETH ARE TOO FORWARD? YES   NO 
DO YOU THINK YOUR FACE IS NOT SYMMETRIC? YES   NO 
DO YOU HAVE CONCERNS WITH THE FULLNESS OF YOUR LIPS? YES   NO 
OTHER CONCERNS:
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