SONDHI-BIGGS-HANSEN ORTHODONTICS

SONDHI-BIGGS-HANSEN ORTHODONTICS
Anoop Sondhi, DDS, MS
www.indyortho.com
Jeffery Biggs, DDS, MS
Vincent Hansen, DMD, MSD
9333 North Meridian Street, Suite 301, Indianapolis, IN 46260
Phone #: (317) 846-1455
E-mail: [email protected]
Fax #: (317) 843-0626
Orthodontics and Temporomandibular Joint Disorders
Adult Clinical History/Family Information
Patient’s Name ___________________________________________________ Age______ Gender______ Birth Date _________________
Last
First
M.I.
Address ______________________________________________________________________________ Tel. # (
Street
City
State
Zip
) ______________
Employed by ___________________________________________ Occupation _____________________ Position _______________________
Employer Address _________________________________________________________________ Work Tel. # (
Zip
City
State
Street
) _______________
Preferred phone number to call for appointments (During Business Hours)____________________________________________
Preferred E-mail Address ______________________________________________________________________________________
Social Security Number of Patient (for accounting purposes only) _____________________________________________________
Marital Status:
Single
Orthodontic Insurance?
Medical Insurance?
Married
Yes
Yes
No
No
Separated
Widowed
Divorced
Partnered
Name of Ins Co _______________________ ID# _________________ Group #_______________
Name of Ins Co _______________________ ID# _________________ Group #_______________
Spouse Name______________________________________________________________ Gender______ Birth Date__________________
Last
First
M.I.
Employed by __________________________________________ Occupation ____________________ Position ____________________
Employer Address _____________________________________________________________________ Work Tel. # (
) __________
Street
City
State
Zip
Social Security Number of Spouse (for accounting purposes only) ____________________________________________________
Orthodontic Insurance?
Medical Insurance?
Yes
Yes
No
No
Name of Ins Co ________________________ ID# ________________ Group #_______________
Name of Ins Co ________________________ ID# ________________ Group #_______________
Responsible Party (if other than the patient/spouse):
Not Applicable
Is Responsible Party authorized to sign consent on behalf of patient?
Yes
No
Name ________________________________ SS # _______________ Birth Date _______________ Relationship to patient ____________
Home Address __________________________________________________________________________ Tel. # (
Orthodontic Insurance?
Medical Insurance?
Yes
Yes
No
No
) _____________
Name of Ins Co _________________________ ID# _______________ Group #_______________
Name of Ins Co _________________________ ID# _______________ Group #_______________
Patient's Family Dentist _______________________________________
Patient's Family Physician ___________________________________
Whom may we thank for referring you to our office? ____________________________________________________________________
MEDICAL HISTORY:
Have you had or do you have any of the following?
Yes
No
Rheumatic Fever
Heart Murmur
High Blood Pressure
Heart Attack/Stroke
Blood Vessel Disease
Blood Disorder
AIDS/HIV Infection
Hepatitis
Diabetes
Ulcers
Herpes (Any type)
Psoriasis
Cancer
Persistent Headaches
Neck Pains
Nerve or Brain Disease
Migraine
Epilepsy
Mental Health Problems
Bone Disorders
Arthritis (Any type)
Artificial Joints
Sleep Apnea
Ear Disorder
Sinus Infection
Swollen Glands
Allergies
Yes
No
Comments ____________________________________________________________________________________________________
Please list any other significant information about your medical history: ______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Yes
No
Are you under a physician's care at present? If yes, reason
Are you presently, or have you ever been, under the care of a psychiatrist or psychologist?
If yes, describe
Are you currently taking any medication? If yes, describe ____________________________________________
Are you allergic to any medications? (e,g: aspirin, penicillin, etc.) If yes, what?___________________________
Have you ever had any general anesthesia? When? _______________________________________________
FEMALE PATIENTS:
Yes
No
Do you have regular menstrual cycles?
Have you experienced menopause?
Has anyone in your family had osteoporosis?
Is there a possibility that you could be pregnant?
DENTAL HISTORY:
Yes
No
Do any of your teeth hurt? If yes,
upper right
upper left
lower right
lower left
Have any wisdom teeth been removed? How many?
Have you ever had treatment for a periodontal disease (gum disease)? If yes, describe _____________________
Have you ever had any previous orthodontic treatment (braces)? If yes, when _____________________________
If yes, doctor’s name and address
Have there been any injuries to your mouth or teeth? If yes, describe _________________________________
Have you ever had any injury in the head and neck area? If yes, describe _____________________________
Have you ever fallen and bumped your chin, or received a blow to your jaws?
If yes, describe ___________________________________________________________________________
Have you ever had any surgery in the head and neck area? If yes, describe ___________________________
Do you clench or grind your teeth? If yes,
while sleeping
under stress
other_____________________
Do your jaw muscles ever feel tired? If yes, when ________________________________________________
Do you ever notice soreness, tightness or pain in the muscles around the jaws and face?
If yes, describe ___________________________________________________________________________
Does it hurt to chew? If yes, where does it hurt? _________________________________________________
Yes No
Do you hear clicking (popping) or grating sounds in your jaw joints?
Right
Left
Clicking
Grating:
Since when
During what activity
____________________
________________
Did these joint sounds begin gradually or suddenly?
gradually
______________________________________________
______________________________________
suddenly
Was there some specific event that started the joint sounds? If yes, describe ________________________________________
Have you ever experienced difficulty in opening or closing your jaws? If yes, describe __________________________________
Have your jaws ever “locked” closed? If yes, describe
Have your jaws ever “locked” wide open? If yes, describe
Do you have pain in your jaw joints? If yes,
right
Did your pain start gradually or suddenly?
gradually
left
Since when? ________________________________________
suddenly
During what activity? ________________________________________ Describe nature of pain ________________________
What increases the pain? ____________________________________ What decreases the pain? ______________________
Do you have any of the following habits?
Yes No
Finger/Thumb Sucking
Lip Biting
Nail Biting
Gum Chewing
Ice Chewing
Smoking or using other tobacco products
Please describe why you sought this consultation ____________________________________________________________________
Have you ever been treated for this problem before? If yes, please describe the diagnosis and treatment:
Have any other members of the family had orthodontic treatment?
Have any other members of the family been patients in this office?
Name(s) ____________________________________________________________________________________________
We recognize that patients sometimes have specific concerns that may not be addressed by the questions in this Clinical
History Form. Please feel free to include any other information regarding your clinical history, or any other concerns that you
may have, in the space below. If necessary, please add another sheet of paper.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find
it accurate. If there are any later changes to my clinical history, I recognize that it is my responsibility to inform this office.
also give my permission for a clinical examination.
________________________________________________
(Patient’s Signature)
Submit
______________________________
Date
Print
Orthodontist’s Notes ____________________________________________________________________________________________________
________________________________________________________________________________________
___________
________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________
(Orthodontist’s Signature)
_________________________________
Date
PATIENT COORDINATOR CHECKLIST AND NOTES
Contacts with other doctors:
1.
2.
3.
Special notes
Additional notes
CN
PATIENT
DATE
TODAY’S PROCEDURE
AST
DR
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NEXT PROCEDURE
2014 Sondhi-Biggs-Hansen Orthodontics