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 _______________________________________________________________________

Email

Email

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)