Springboro: 937-746-3405
Patient Login
General Dentist
Last Visit How did you hear about our Practice? Ad Internet Family/Friend Physician Other Name of person referring (if applicable) What are the main concerns you would like orthodontics to accomplish? Has your child visited an orthodontist before? Yes No When? Reason? Has your child's tonsils or adenoids been removed? Yes No Has your child ever experienced jaw joint pain/ discomfort (TMJ/TMD)? Yes No Does your child have any missing or extra permanent teeth? Yes No Has your child ever had an injury to (select all that apply): Teeth Mouth Chin Does your child have speech problems? Yes No If so, explain Does your child currently or has your child ever had any of the following habits? Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail biting Thumb/Finger Sucking Chewing/Eating Problem Medical History Is your child currently being treated by a physician? Yes No Reason Physician Last Visit Phone Does your child have any allergies/sensitivities to medications or latex? Yes No If yes, please list allergies: Is your child currently taking any prescription or over-the-counter medications? Yes No Please list, with dosage: Has puberty and/or menstruation begun? Yes No NA Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No Has your child had any serious illnesses or operations? If yes, describe Has your child had any serious illnesses or operations? If yes, describe Has your child ever had a blood transfusion? Yes No If yes, give approximate dates: Is your child pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No Check if your child has or has ever had any of the following Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD) Authorization I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. Patient Signature and/or Responsible Party Date
Name of person referring (if applicable) What are the main concerns you would like orthodontics to accomplish?
When? Reason?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
