Financially Responsible Party Information

Relationship to Patient

Self

Mother

Father

Spouse

Other

Dental Insurance Information

Emergency Contact Information

Medical History

Please check Yes or No

Is the patient in good health?

Yes

No

Please circle Yes or No (If Yes, please fill in details)

Are you taking any medication?

Yes

No

Are you allergic to any medication?

Yes

No

Do you have a history of a major illness?

Yes

No

Have you had any major operations?

Yes

No

Have you ever been involved in a serious accident?

Yes

No

Circle any of the medical conditions below taht you have had or currently have

Please check any of the medical conditions below that you have had or currently have

Abnormal bleeding/Hemophilia

Anemia

Arthritis

Asthma or Hay fever

Bone Disorders

Congenital Heart Defect

Diabetes

Hepatitis/Liver problems

Pneumonia

Dizziness

Herpes

Epilepsy

High Blood Pressure

Prolonged Bleeding

Radiation/Chemotherapy

Gastrointestinal Disorders

HIV/Aids

Rheumatic Fever

Heart Problems

Kidney problems

Tuberculosis

Heart Murmur

Nervous Disorders

Tumor or Cancer

Dental History

Please check Yes or No

Are you presently in any dental pain?

Yes

No

Have you ever experienced any unfavorable reaction to dentistry?

Yes

No

Have you ever lost or chipped any teeth?

Yes

No

Have there been any injuries to face, mouth or teeth?

Yes

No

Is any part of your mouth sensitive to temperature or pressure?

Yes

No

Do your gums bleed when you brush?

Yes

No

Do you have any type of thumb or tongue habit?

Yes

No

Are you a mouth breather?

Yes

No

Have you ever seen an orthodontist? If yes, who and when?

Yes

No

Would you object to wearing orthodontic appliances (braces) should they be indicated?

Yes

No

Has anyone in your family received orthodontic treatment?

Yes

No

Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

Yes

No

Are you aware of your jaw clicking or popping?

Yes

No

Are you aware of clenching your teeth during the day?

Yes

No

Have you ever been told that you grind your teeth?

Yes

No

Do you have "tension" headaches?

Yes

No

Have you ever experienced chronic ringing in your ears?

Yes

No

Female Patients only

Are you pregnant?

Yes

No

Female Patients under age 18

Has menstruation started?

Yes

No

BENEFITS & ACKNOWLEDGMENT

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Fernando A. Vignolo to perform a complete orthodontic evaluation.

I have accept the terms listed in the paragraph above *

Yes