email - east tennessee orthodontics...2019/02/06 · east tennessee orthodontics • justin...
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East Tennessee Orthodontics • Justin Trisler, DMD, MS Oak Ridge, TN • 865-312-6264
(For Patients Age 18 And Under)
Today's Date ___________________________________
Patient Name ____________________________________ Prefers to be called ________________________________
Address ______________________________________________________________________________________
City, State, Zip _______________________________________________________________________________________
Home Phone ____________________________________ Birthdate ______________________ Age _________ Sex M F
Who may we contact in case of emergency? ______________________________________ Phone _________________
Family Dentist ___________________________________ Family Physician ____________________________________
In your opinion, what is your orthodontic problem? _____________________________________________________
Who may we thank for recommending you for an appointment? ___________________________________________
Father's Name ___________________________________ Birthdate ____________________ Phone _________________
Occupation ______________________________________ Employed by _____________________________________
Mother's Name __________________________________ Birthdate ____________________ Phone _________________
Occupation ______________________________________ Employed by _____________________________________
Father's work # ___________________________________ Mother's work # ____________________________________
Brothers and Sisters:
Name _________________________ Birthdate ___________ Name _____________________ Birthdate __________
Name _________________________ Birthdate ___________ Name _____________________ Birthdate ____________
Has any other member of the family had orthodontic treatment? No Yes
Person responsible for account ______________________________________________________________________
If divorce is involved, who is the Custodial Parent? ________________________________________________________
May patient information be released to the noncustodial parent? No Yes
Address ______________________________________________________________________________________
City, State, Zip _______________________________________________________________________________________
Do you have orthodontic insurance coverage? No Yes, company __________________________________
Group Number __________________________________ Phone/Contact ____________________________________
Social Security # ___________________________________________________________________________________
Secondary Insurance Coverage _______________________________________________________________________
East Tennessee Orthodontics • Justin Trisler, DMD, MS Oak Ridge, TN • 865-312-6264
HEALTH QUESTIONNAIRE
Today’s Date
Patient Name Birthdate
Date of last dental visit or check-up ___________
Have you ever had the following dental treatment?
Orthodontics, Date ___________ , by Dr. ___________
Periodontal treatment (gum treatment) Mouthguard or splint therapy for jaw joint problems Therapy for an oral habit or speech therapy
Do you have or have you had any of the following oral conditions?
Bleeding gums
Bad Breath Food wedging between teeth
Injury or blow to the chin or jaw Dry Mouth
Oral habits (thumb sucking, etc)Mouth BreathingClenching or GridingPain in jaw or face Pain when opening or closing mouth Pain around ear Discolored teeth
Sensitive Teeth
Poorly functioning teeth Swelling or lumps in the mouth
Jaw joint sounds or pain Jaw gets stuck open or closed Tobacco use
Do you have or have you had any of the following medical conditions?
Rheumatic Fever Congenital heart lesions / murmur Psychological problems Diabetes Anemia Asthma Sleep Apnea Kidney problems Learning Disabilities
Arthritis (any type) Heart condition Severe Headaches Liver disease High blood pressure Dizziness or Fainting
Hepatitis type ______ Low blood pressure Convulsions or seizure Yellow jaundice Ear problems Sinus problems Chronic Pain Disorders Eye problems Swallowing problems Easy bruising HIV positive Speech problems
no
no no
no
Are you currently under a physician’s care? If yes, describe _____________________________ yes
Has patient ever been hospitalized or had any serious illness? If yes, describe ____________ _ yes
Does the patient have any drug allergies? If yes, list medications _________________________ yes
Is the patient allergic to latex? yes
Is the patient taking any medication? If yes, list medications _____________________________ yes no
Growth and Development No Yes When?
No Yes When?
Has the patient begun adolescent growth Girls: Has monthly periods started yetBoys: Has voice changed yet No Yes When?
Father’s Height Mother’s Height Older Siblings’ Heights
Parent’s/Gardian's signature _____________________________________ Date
Notes:
Thank you for choosing East Tennessee Orthodontics. Help us get to know you better.
Name:________________ Birthday:_________ School:__________________________________ What is your favorite activity: (sport, hobby, ect.) __________________________________________ What do you want to be when you grow up?__________________________________________ Favorite Band/Artist:_________________________ Favorite Movie:_____________________________ Favorite Sports Team:________________________ What is the best vacation you have ever taken?__________________________________________ Do you have any brothers or sisters and if so what are their names?____________________________ Do you have any friends that go to the Orthodontist?______________________________
865-312-6264www.easttnorthodontics.com
Pediatric Sleep Questionnaire
Patient Name: _________________________________ Today’s Date: _______________
Dr. Trisler would like you to complete this form as accurately and honestly as possible.
In our practice we are very interested in our patients’ overall health. Orthodontic
treatment can be an important part of managing the health problems caused by sleep
and breathing disorders.
Has your child had their tonsils/adenoids removed? ___Y ____N, Date___________
____ While Sleeping, does your child snore more than half of the time? ____ While Sleeping, does your child always snore? ____ While Sleeping, does your child snore loudly? ____ While Sleeping, does your child have “heavy” or loud breathing? ____ While Sleeping, does your child have trouble breathing, or struggle to breathe? ____ Have you ever seen your child stop breathing during the night? ____ Does your child occasionally wet the bed, sleepwalk, or have night terrors (circle any)? ____ Does your child tend to breathe through the mouth during the day? ____ Does your child have a dry mouth upon waking in the morning? ____ Does your child wake up unrefreshed in the morning? ____ Does your child wake up with headaches in the morning? ____ Is it hard to wake up your child in the morning? ____ Does your child have a problem with sleepiness during the day? ____ Has a teacher or caregiver commented, ‘your child appears sleepy during the day’? ____ Did your child stop growing at a normal rate at any time since birth? ____ Is your child overweight? ____ Your child often does not seem to listen when spoken to directly. ____ Your child often has difficulty organizing task and activities. ____ Your child is often easily distracted by extraneous stimuli. ____ Your child often fidgets with hands or feet or squirms in seat. ____ Your child is often ‘on the go’ or often acts as if ‘driven by a motor’. ____ Your child often interrupts or intrudes on others (butts into conversations or games).
Total Score = _____
For our practice, Orthodontics is MUCH more than straight teeth!
(Ronald D Chervin, et al Arch Otolaryngol Head Neck Surg. 2007; 133 (3): 216-222)
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