Microsoft word - info_med hx.doc

Sletten & Brettin Orthodontics
Specialists in Orthodontics and Dentofacial Orthopedics 6303 Osgood Avenue N, Suite 205, Stillwater, MN 55082  Phone 651-439-3350
400 2nd Street S, Suite 230, Hudson, WI  Phone 715-377-2155
Patient Information
Patient’s Name __________________________________________ Home Phone _________________
Birthdate _________________________ M/F _________ Cell Phone _____________________________ School ____________________________________ Employer __________________________________ Address ______________________________________________________________________________ Patient’s Dentist ____________________________ Patient’s Physician ___________________________ Whom may we thank for referring you to our office?____________________________________________ Responsible Party Information
Name ________________________________________________________________________________
Address ______________________________________________________________________________ Home Phone ___________________________ Work Phone ____________________________________ Employer _________________________________________ Cell Phone___________________________ E-mail address _________________________________________________________________________
Spouse’s Name ________________________________________________________________________
Home Phone ___________________________ Work Phone ____________________________________ Employer _________________________________________ Cell Phone___________________________ Orthodontic Insurance Information
Primary Insurance Company_____________________________________________________________
Insured’s Name _________________________________________ Birthdate _______________________ Employer _________________________________________ SS or ID # ___________________________ Insurance Co. Address ___________________________________________________________________ Insurance Co. Phone # __________________________ Group/Local # _____________________________ Secondary Insurance Company __________________________________________________________
Insured’s Name _________________________________________ Birthdate _______________________ Employer _________________________________________ SS or ID # ___________________________ Insurance Co. Address ___________________________________________________________________ Insurance Co. Phone # __________________________ Group/Local # _____________________________ Medical History
Are you currently under a doctor’s care? ………………………………………. Y ___ N ___ Doctor’s name __________________________________________________________ last examination date _____________________ Have you had a heart, blood vessel, lung, kidney, or joint replacement surgery? …. Y ___ N ___ Have you been hospitalized in the past 2 years? ………………………………. Y ___ N ___ why? __________________________________________________________________________________________________________ Have you taken any medication in the last six months? (circle) high blood pressure, insulin, heart, tranquilizers, blood thinner, ……. Y ___ N ___ steroids, aspirin, asthma, Parkinson’s, DIET medication, anti-depressents, herbal supplements, or other medications? list all medications _______________________________________________________________________________________________ Do you have any allergies? (circle) drugs, aspirin, codeine, penicillin, keflex? ………………………………. Y ___ N ___ other __________________________________________________________________________________________________________ Do you smoke (pipe, cigar, cigarettes)? packs per day __________ ? for how long __________ ? ……………………. Y ___ N ___ Have you or any member of your family had a bad experience with a general or local anesthetic? …………. Y ___ N ___ Have you had any of the following? (please circle to indicate a “yes” answer)
polycystic ovarian disease
Females only
Are you or could you be pregnant? months __________ ? ………………………………. Y ___ N ___
Do you have a menstrual cycle? .………………. Y ___ N ___
Are you using or have you ever used the birth control pill? .…………. Y ___ N ___
Which brand of birth control pill are you taking or have taken? ________________________________________________________________ Orthodontic History
Have you worn braces in the past? ……………….………………. Y ___ N ___ Have you consulted with another orthodontist? ………………………………. Y ___ N ___ If yes, were any of the following discussed?: Extraction of upper teeth? . Y ___ N ___ Extraction of lower teeth? . Y ___ N ___ Roof of the mouth appliance? . Y ___ N ___ What is the reason for your visit?: ( ) bite correction
( ) dental/smile esthetics ( ) facial esthetics( ) TMJ treatment
What is your impression of the type of treatment needed?:
Please list any special concerns or provide any additional information that you feel would be beneficial to share with the doctor: ____________
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Signature______________________________________________________________ Date___________________
2009 Sletten & Brettin Orthodontics

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