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PATIENT DETAILS






















YesNoIs the patient a minor?
RESPONSIBLE PARTY / INSURANCE INFORMATION













INSURANCE (IF APPLICABLE):




RESPONSIBLE PARTY 2 / INSURANCE INFORMATION
YesNo Is there a second guardian and / or additional insurance to add?













OTHER INSURANCE (IF APPLICABLE):




SLEEP / AIRWAY ISSUES
YesNoDoes the patient tend to be a mouthbreather?
YesNoDoes the patient snore at night?
YesNoDoes the patient seem rested in the morning?
YesNoIs the patient often sleepy during the day?
YesNoHas the patient seen an Ear, Nose & Throat Specialist?
YesNoIs the patient using a sleep apnea device?
DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

AIDS
Alzheimer's/Dementia
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Coughing, Persistent
Cough up Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmer
Heart Problems Other
Hemophilia
Hepatitis
High Blood Pressure
HIV Positive
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Disorders
Pacemaker
Psychiatric Care
Radiation Treatment
Respitory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Infection
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Vitamin B12 Deficiency

YesNoHave you ever been treated for osteopporosis?
YesNoAre you or have you ever taken Bisphosphonates such as: Fosamax, Actonel, Boniva, Zometa or Aredia?
YesNoHave you ever taken Redux or Fen-Phen
YesNoDo your gums bleed when you brush?
YesNoIs the patient seeing any other dental specialists?
YesNoAny dental restorations needing to be completed?
YesNoHave there ever been any injuries to the face, mouth or chin?
YesNoHave you ever lost or chipped any teeth?
YesNoDo you have any pain or soreness around your face, neck or back?
YesNoIs any part of your mouth sensitive to temperature or pressure?
YesNoIs the patient currently pregnant?
YesNoHave adenoids been removed?
YesNoHave tonsils been removed?
YesNoCurrently taking any medications?
YesNoAre antibiotics necessary prior to treatment?
YesNoAllergies?
YesNoAny diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip biting
Clenching/Grinding Teeth
Fingernail Biting
Thumb Sucking
SIGNED CONSENT