Patient Info
Patient's Last Name
First Name
Middle Initial
TitleSelectMr.Mrs.Ms.Miss.Dr.Other
If other, preferred title
I prefer to be called
Birth Date
SexSelectMaleFemale
Identify as:
Home Address
City
Province
Postal Code
Cellular Number
Home Number
Work Number
Email Address
Occupation
Employer
Who referred you to this office?
Who first noticed the need for orthodontic care?
Reason for Orthodontic Consultation:
Have you had a previous consultationSelectYesNo
If yes, when?
Closest Relative
Spouse or closest relative's name:
Relationship to patient:
Dentist / Physician
Patient's Dentist
Address, City, Province
Last Seen
Reason
Next Appointment
Other dentists/dental specialists now being seen:
Name
City, Province
Family Doctor
NIHB Insurance
Do you have Indian Status?SelectYesNo
If yes, please provide the following information.
Band Name
Band Number
Full name (as appears on card)
Medical & Dental History
Please check which conditions you have or have been treated forSelect all that applyType I DiabetesType II DiabetesAsthmaEpilepsyHeart ConditionsBone DisordersBlood/bleeding disordersImmune Suppression
Please list all current and recent medications below:
Medication
Please list any current or previous major illnesses that were not mentioned above:
Please ensure that you have included ALL medications & treatments including bisphosphonates, chemotherapy, radiotherapy, corticosteroid and any immune suppressants.
Any allergies to medications?SelectYesNo
If yes, please indicate:
Any allergies to metals/latex?SelectYesNo
Do you / did you have any of the following?
Tonsils and/or adenoids have been removed?SelectYesNo
Any injuries to the face, mouth or teeth?SelectYesNo
Thumb/finger sucking habit?SelectYesNo
Speech problems that you would like to address?SelectYesNo
Clicking or discomfort in the jaw?SelectYesNo
Grinding or clenching of teeth?SelectYesNo
Difficulty in chewing?SelectYesNo
Extensive dental work or gum problems?SelectYesNo
Are you concerned or have reservations about?
Co-operation for approximately 2 years?SelectYesNo
Wearing braces?SelectYesNo
Appearance of your face, lips, gums, or teeth?SelectYesNo
Monday – Friday 7:30 – 4:00
1-800-123-1234
[email protected]
343 O’Connell Dr. Corner Brook, NL A2H 7V3, Canada
