Orthodontist - Matza & Co. Orthodontics - Orthodontist

Click here to download a printable version


Patient Name
	Last	First	Middle Initial
Address
	Street

	City	State	Zip
Home Phone Cell Phone
Birth Date SS#
If patient is a minor, give parent's or guardian's name.
Whom may we thank for referring you to our office?


Name
	Last	First	Middle Initial	Marital Status
Address
	Street

	City	State	Zip
How long at this address:
Home Phone:	Work Phone:	Cell Phone:
Previous Address (If less than 3 years)
	Street

	City	State	Zip
SS# Birth Date: Relationship to Patient:
Employer: Occupation: Number Years Employed:
Employer Address:
Spouse Information
Spouse's Name
	Last	First	Middle Initial
SS# Birth Date: Relationship to Patient:
Employer: Occupation: Number Years Employed:
Work Phone:


Insured's Name	Insured's Social Security #
Insurance Company	Group Number	Local Number
Insurance Company Address:
Insurance Company Phone Number:
Insured's Employer:


Name of nearest relative not living with you:
Complete Address:
Phone Number:


General Dentist Name:
Dentist Address: Dentist Phone:
What are the main concerns that you would like orthodontics to accomplish?
	YES	NO
Previous orthodontic treatment? If so when?
Have you ever been evaluated for orthodontic treatment?
Attitude toward orthodontic treatment: Good None Resentful
Best benefit to be obtained from orthodontic treatment: Cosmetic Psychological Functional
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD )?
Do you like your smile? If not, what don't you like?
Do your gums ever bleed?
Do you have any speech problems? If yes, explain
Do you generally breathe through your mouth while awake?
Do you generally breathe through your mouth while asleep?
Have there been any injuries to the face, mouth teeth or chin?
Do you have missing or extra permanent teeth?
Have adenoids or tonsils been removed?
Are you pregnant? If yes what week number
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?	YES	NO
Aspirin
Any Metals / Plastics
Codeine
Dental Anesthetics
Erythromycin
Latex
Penicillin
Tetracycline
Other
Please list any other drugs that you are allergic to :
What is your e-mail address?

Have you ever had any of the following diseases or medical problems ?

YES

Abnormal Bleeding

Heart Attack / Stroke

Allergies to any drugs

Heart Murmur

Anemia / Radiation Treatment

Heart Surgery / Pacemaker

Any Hospital stays

Hemophilia / Abnormal Bleeding

Any Operations

Hepatitis

Artificial Bones / Joints

High / Low Blood Pressure

Artificial Valves

HIV+ / AIDS

Asthma / Arthritis

Hospitalized for any reason

Blood Transfusion

Kidney Problems

Cancer / Chemotherapy

Mitral Valve Prolapse

Congenital Heart Defect

Psychiatric Problems

Diabetes / Tuberculosis (TB)

Rheumatic / Scarlet Fever

Difficulty Breathing

Severe / Frequent Headaches

Drug / Alcohol Abuse

Shingles

Emphysema / Glaucoma

Sinus Problems

Epilepsy / Seizures / Fainting Spells

Tuberculosis (TB)

Fever Blisters / Herpes

Ulcers / Colitis

Handicaps / Disabilities

Venereal Disease

Hearing Impairment / PE Tubes

Please list any serious medical conditions that you have ever had:

If patient is a child does/did your child have any of the following habits?

YES

Clenching / Grinding Teeth

Nursing Bottle Habits

Lip Sucking / Biting

Speech Problems

Mouth Breather

Thumb / Finger Sucking

Nail Biting

Tongue Thrust

Name the patient would like to be called
Cell Phone Sex: Male Female
Marital Status of Parents:
If divorced, please list custodial parent:
Parent Child Resides With: Mother Father Legal Guardian Both
Guardian Name:
Address: Phone:
School
Hobbies
List Brothers & Sisters and Ages
General Dentist
Dentist Address: Dentist Phone:
Date of Last Visit
Family Physician
Phone Number
Date of Last Visit
Are you under the care of a physician?	Yes No
Please Explain
Are you taking any prescription/over the counter drugs?	Yes No
Please list each one
Signature
Date