WSJ

Dr. Sima Yakoby, DMD

ORTHODONTIC ACQUAINTANCE FORM
Adult


Date
 		Date of Birth

 

Patient's Name

Last
 First
 Middle
Social Security #
Age  
    		Sex  
    		Height  
Weight
Residential Address
 Phone #
 		Apt.#
City
 State
 Zip
Email Address

Referred By

Medical Contacts
Dentist Physician
Address Address
Periodontist  Oral Surgeon

Patient's Information
Occupation Employed By
Bus. Address  Bus. Phone

Spouse's Information
Spouse's Name Occupation
Employed By  Bus. Phone
Bus. Address  Spouse's Dentist
Person Assuming Financial Responsibility
Address
Apt.#
 City & State
Names & Ages Of Children In Family
Person To Contact In Case Of Emergency
 Phone #


Reason For Consultation

Medical History
Are you in good health? Yes No
Do you have any history of major illness? Yes No
Have you ever been under the care of a physician for illness? Yes No
Have you ever been hospitalized? Yes No
Please explain
Date of last examination by physician
Do you bruise easily? Yes No
Have you ever required a blood transfusion? Yes No
Do you have a tendency to colds? Yes No
Do you have a tendency to sore throats? Yes No
Have tonsils and/or adenoids been removed? Yes No
If yes, at what age?
Do you have chronic ear pain or infections? Yes No
Do you take sedatives, tranquilizers, sleeping pills or medicine to relax? Yes No
Do you have trouble sleeping? Yes No
Do you snore when sleeping? Yes No
List any drugs or medication now or previously taken:
If Female, are you pregnant? Yes No
Taking birth control pills? Yes No
 

Please indicate "yes" or "no" to any condition you have experienced:
Heart murmur............................................................ Yes No
Rheumatic Fever........................................................ Yes No
High blood pressure................................................... Yes No
Low blood pressure.................................................... Yes No
Hepatitis................................................................... Yes No
Diabetes................................................................... Yes No
Kidney disease.......................................................... Yes No
Asthma..................................................................... Yes No
Tuberculosis.............................................................. Yes No
Pneumonia................................................................ Yes No
Often fatigued/exhausted ........................................... Yes No
Nervous/anxious........................................................ Yes No
Any recent weight gain/loss........................................ Yes No
Cancer treatment....................................................... Yes No
Sinus Trouble............................................................ Yes No
Epilepsy.................................................................... Yes No
Fainting..................................................................... Yes No
Arthritis..................................................................... Yes No
Anemia/blood disease................................................ Yes No
Tumors/growths......................................................... Yes No
Thyroid/parathyroid problems...................................... Yes No
Bone disorders.......................................................... Yes No
Seizures................................................................... Yes No
Endocrine problems................................................... Yes No
Frequent headaches.................................................. Yes No
Immune system problems.......................................... Yes No
Psychiatric care........................................................ Yes No
Prolonged bleeding.................................................... Yes No

 

Are you allergic or have reacted adversely to:
Local anesthetics....................................................... Yes No
Penicillin/other antibiotics............................................ Yes No
Sulfa drugs................................................................ Yes No
Barbiturates, sedatives or sleeping pills........................ Yes No
Aspirin....................................................................... Yes No
Iodine........................................................................ Yes No
Codeine or other narcotics........................................... Yes No
Other:
Dental History
Date of your last dental examination or treatment .............................................................
Have you had any serious problems associated with previous dental treatment?.................. Yes No
Have there been any injuries to your face, mouth or teeth?................................................. Yes No
Has there been any treatment for problems of your jaw joint or for facial muscle spasms?..... Yes No
Have you ever sucked a thumb or fingers?........................................................................ Yes No
Until what age?..............................................................................................................
Do you have any speech problems?................................................................................. Yes No
Are you a mouth breather?.............................................................................................. Yes No
At what times?...............................................................................................................
Have you been informed of any missing or extra teeth?...................................................... Yes No
Does food catch or collect between your teeth?................................................................ Yes No
Do you clench or grind teeth?.......................................................................................... Yes No
Is there clicking, popping or grating noise from your jaw when chewing?.............................. Yes No
Is there numbness or tingling associated with your mouth or face?..................................... Yes No
Have you ever had orthodontic treatment or been treated for a bad bite?.............................. Yes No
Has an orthodontist been consulted previously?................................................................ Yes No
Have you ever had periodontal (gum) disease?.................................................................. Yes No
Has either parent had orthodontic treatment?.................................................................... Yes No
Has either parent had periodontal disease?....................................................................... Yes No
Do you use a mouthguard or plastic splint?...................................................................... Yes No
List any musical instruments played:
 
 
 
By typing in your initials in the box here, you attest that the above information supplied is correct and is only intended for use in the offices of Dr. Marc Lemchen and Dr. Jennifer Salzer.

Please Click on the "SIGN FORM" Button at the top of the screen to sign this Form. Then click on the "ACCEPT" Button to accept your signature. 

To complete the process please click on the "SUBMIT FORM" Button at the top of the screen.