Ortho Perfection

GENERAL INFORMATIONS

Hidden

** Attention

Patient’s Last Name*

Patient's First Name*

Age*

Date of birth*

Genre*

M
F

Home Phone

Mobile

Work Phone

Address*

Address Address 2 City Province Postal Code

Are you under 18?

Yes
No

Parent 1 Name

Phone Home

Mobile

Phone Work

Parent 2 Name

Phone Home

Mobile

Phone Work

Person in charge of payments

Parent 1
Parent 2
Other

Specify other

Email*

Insurance?*

Yes
No

You have been referred to our office by

DENTAL HISTORY

Name of your current dentist: Dr.*

Last visit at the dentist*

0-6 months
6-12 months
12+ months

Have you had a panoramic x-ray in the past year?*

Yes
No

Date of radiography

Have you ever had an orthodontic consultation?*

Yes
No

Date of orthodontic consultation*

Do you play a musical instrument?*

Yes
No

Which one?*

Have you ever had an accident involving the head or face?*

Yes
No

Have you ever had a dental trauma (blow to the teeth, fracture of a tooth or teeth, etc.) ?*

Yes
No

Have you ever had surgery on the head, the face, the jaws or in the mouth?*

Yes
No

Have you ever had orthodontic treatment?*

Yes
No

Have you ever had teeth extracted for orthodontic reasons?*

Yes
No

Do you have any trouble opening your mouth?*

Yes
No

Do your jaw joints crack or make noises?*

Yes
No

Do your gums bleed?*

Yes
No

Are your teeth sensitive?*

Yes
No

Oral Habits (check all that apply)

Thumb sucking
Tongue thrusting
Mouth breathing
Speech impediment
Lip biting
Nail biting
Jaw clenching
Tooth grinding
Other

Specify other habit*

MEDICAL HISTORY

Name and address of your family doctor: Dr*

Date of your last medical examination

Are you presently under the care of a physician?*

Yes
No

If so, for what reason?*

Do you take any medication or have you taken any in the last six months?*

Yes
No

If so, which ones?*

Do you take the birth control pill?*

Yes
No

Teenage girls: Did you have your first period? If so, at what age?

Teenage boys: Did your voice start changing? If so, at what age?

Are you pregnant?*

Yes
No

Do you smoke?*

Yes
No

Did you ever have an allergic reaction to medication, food, nickel or any other substance?*

Yes
No

If so, specify:

Have you ever been hospitalized?*

Yes
No

If so, for what reason?

Do you suffer or have you ever suffered from the following?

Heart problems*

Yes
No

Rhumatic fever or endocarditis*

Yes
No

Prolonged bleeding*

Yes
No

Anemia*

Yes
No

Blood pressure problems*

Yes- High
Yes - Low
No

Frequent colds or sinusitis*

Yes
No

Tuberculosis or lung problems*

Yes
No

Asthma*

Yes
No

Removal of tonsils or adenoids*

Yes
No

HIV virus carrier*

Yes
No

Psychological or emotional disorder*

Yes
No

Digestive problems*

Yes
No

Liver problems (hepatitis, cirrhosis)*

Yes
No

Kidney problems*

Yes
No

Sexually transmitted disease (STD)*

Yes
No

Diabetes*

Yes
No

Thyroid problems*

Yes
No

Skin disease*

Yes
No

Eye problems*

Yes
No

Arthritis*

Yes
No

Epilepsy*

Yes
No

Frequent headaches*

Yes
No

Dizzyness, fainting*

Yes
No

Earaches*

Yes
No

Hay fever*

Yes
No

Persistent cough*

Yes
No

Mononucleosis*

Yes
No

Radiation therapy for tumor or other reasons*

Yes
No

Other pertinent medical or dental information

ACCEPTANCE

Medical and dental history*

I hereby declare that I have read, understood, and answered the above medical and dental questionnaire to the best of my knowledge.

Acceptance of Collection, use, and disclosure of personal information*

I hereby give my consent to the collection, use and disclosure of my personal information by ORTHO PERFECTION for the purpose of providing dental services.

Read our Privacy Policy

Patient or Parent Signature*

Printed name*

Date

Réservé à l'administration

RESERVED FOR ADMINISTRATION

Notes

Precautions

Acceptance of the specialist*

I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.

Specialist Signature

Specialist Name*

Date

Hidden

is Approval

Who is this for?

Me