Date
Date of Birth

 

Patient's Name

Last
First
Middle
Social Security #
Age  
   
Sex  
   
Height  
Weight
Residential Address
Apt.#
City
State
Zip
Email Address
Daytime Phone #
Evening Phone #
Cell Phone #
School
Grade
Summer Camp
Summer Tel.

Referred By

Patient's Medical Contacts
Dentist Pediatrician
Address Address

Father's Information
Name Dentist
Oral Surgeon  Occupation
Employed By  Bus. Phone
Bus. Address  Email Address

Mother's Information
Name Dentist
Oral Surgeon  Occupation
Employed By  Bus. Phone
Bus. Address  Email Address

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 (2000 character maximum):



   Insurance Information
Primary Insurance Information   
Employer Name
Insurance Company Name
Insurance Company Address
Insurance Phone #
Group Number
Subscriber ID

Secondary Insurance Information   
Employer Name
Insurance Company Name
Insurance Company Address
Insurance Phone #
Group Number
Subscriber ID



Medical History
Is the patient in good health? Yes No
Does patient have any history of major illness? Yes No
Has patient ever been under the care of a physician for illness? Yes No
Has patient ever been hospitalized? Yes "32%">Yes No
Does patient have trouble sleeping? Yes No
Does patient snore when sleeping? Yes No
List any drugs or medication now or previously taken (2000 character maximum):
 

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

 

Is patient 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 (2000 character maximum):

Dental History
Date of patient's last dental examination or treatment .............................................................
Has the patient had any serious problems associated with previous dental treatment?.................. Yes No
Have there been any injuries to patient's face, mouth or teeth?................................................. Yes No
Has there been any treatment for problems of patient's jaw joint or for facial muscle spasms?..... Yes No
Has patient ever sucked a thumb or fingers?........................................................................ Yes No
Until what age?..............................................................................................................
Does patient have any speech problems?................................................................................. Yes No
Is patient a mouth breather?.............................................................................................. Yes No
At what times?...............................................................................................................
Has patient been informed of any missing or extra teeth?...................................................... Yes No
Does food catch or collect between patient's teeth?................................................................ Yes No
Does patient clench or grind teeth?.......................................................................................... Yes No Yes No
Until what age?..............................................................................................................
Does patient have any speech problems?................................................................................. Yes No
Is patient a mouth breather?.............................................................................................. Yes No
At what times?...............................................................................................................
Has patient been informed of any missing or extra teeth?...................................................... Yes No
Does food catch or collect between patient's teeth?................................................................ Yes No
Does patient clench or grind teeth?.......................................................................................... Yes No
Is there clicking, popping or grating noise from patient's jaw when chewing?.............................. Yes No
Is there numbness or tingling associated with patient's mouth or face?..................................... Yes No
Has patient ever had orthodontic treatment or been treated for a bad bite?.............................. Yes No
Has an orthodontist been consulted previously?................................................................ Yes No
Has patient ever had periodontal (gum) disease?.................................................................. Yes No
Has either parent had orthodontic treatment?.................................................................... Yes No
Has either parent had periodontal disease?....................................................................... Yes No
Does patient 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. Bella Shen Garnett.

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