David E. Hoffman, DMD, DHSc 11144 N Frank Lloyd Wright Blvd #220 Scottsdale, AZ 85259 (480) 451-3088 www.thesmilecreators.com Specialist in Orthodontics for Children and Adults Please present this questionaire at the consultation appointment PATIENT INFORMATION LAST NAME: FIRST NAME, MIDDLE INTIAL: MAILING ADDRESS: NICKNAME: CITY: EMAIL ADDRESS: STATE: FAX: IS PATIENT ADOPTED? SSN: SEX: ZIP: HOME PHONE: WORK PHONE: BIRTHDATE: CELL PHONE: WHEN AND WHERE ARE THE BEST TIMES TO REACH YOU? YES NO SCHOOL (IF STUDENT): GRADE: EMPLOYED BY: MARITAL STATUS: SINGLE MARRIED # OF YEARS: DIVORCED HOW LONG THERE? OCCUPATION: GENERAL DENTIST: DATE OF LAST VISIT: OTHER FAMILY MEMBERS SEEN BY US: WIDOWED SEPARATED EMPLOYER'S ADDRESS: WHO MAY WE THANK FOR REFERRING YOU? NAMES & AGES OF OTHER CHILDREN: WHAT WOULD YOU LIKE ORTHODONTIC TREATMENT TO ACCOMPLISH? PATIENT'S ATTITUDE TOWARD ORTHODONTIC TREATMENT: VERY MOTIVATED WILL COOPERATE IF NEEDED NOT MOTIVATED PARENT INFORMATION (IF PATIENT IS MINOR) PARENT MARITAL STATUS? WHO HAS CUSTODY OF THE CHILD? FATHER'S NAME: MOTHER'S NAME: ADDRESS (IF DIFFERENT FROM PATIENT): ADDRESS (IF DIFFERENT FROM PATIENT): CITY: STATE: ZIP: CITY: STATE: HOME PHONE: CELL PHONE: HOME PHONE: CELL PHONE: WORK PHONE: FAX: WORK PHONE: FAX: SSN: BIRTHDATE: SSN: BIRTHDATE: EMAIL ADDRESS: EMPLOYER: HOW LONG THERE? AGE: EMAIL ADDRESS: OCCUPATION: EMPLOYER: EMPLOYER'S ADDRESS: HOW LONG THERE? 1 OCCUPATION: EMPLOYER'S ADDRESS: ZIP: David E. Hoffman, DMD, DHSc 11144 N Frank Lloyd Wright Blvd #220 Scottsdale, AZ 85259 (480) 451-3088 www.thesmilecreators.com Specialist in Orthodontics for Children and Adults In separation or Divorce situations, the individual who initiates services with us is held financially responsible. INFORMATION ABOUT PERSON RESPONSIBLE FOR THIS ACCOUNT RESPONSIBLE PARTY: RELATIONSHIP TO PATIENT: HOME OR MAILING ADDRESS: EMPLOYED BY / OCCUPATION: CITY: STATE: FAX: HOME PHONE: CELL PHONE: WORK PHONE: BIRTHDATE: SSN: EMAIL ADDRESS: ZIP: PRIMARY DENTAL INSURANCE INFORMATION INSURANCE COMPANY NAME: INSURANCE COMPANY ADDRESS: INSURANCE COMPANY PHONE: GROUP POLICY NUMBER: INSURED'S DATE OF BIRTH: INSURED'S SSN: INSURED'S EMPLOYER: INSURED'S RELATIONSHIP TO PATIENT: SECONDARY DENTAL INSURANCE INFORMATION (IF APPLICABLE) INSURANCE COMPANY NAME: INSURANCE COMPANY ADDRESS: INSURANCE COMPANY PHONE: GROUP POLICY NUMBER: INSURED'S DATE OF BIRTH: INSURED'S SSN: INSURED'S EMPLOYER: INSURED'S RELATIONSHIP TO PATIENT: MEDICAL INSURANCE INFORMATION INSURANCE COMPANY NAME: INSURANCE COMPANY ADDRESS: INSURANCE COMPANY PHONE: GROUP POLICY NUMBER: INSURED'S DATE OF BIRTH: INSURED'S SSN: INSURED'S EMPLOYER: INSURED'S RELATIONSHIP TO PATIENT: 2 David E. Hoffman, DMD, DHSc 11144 N Frank Lloyd Wright Blvd #220 Scottsdale, AZ 85259 (480) 451-3088 www.thesmilecreators.com Specialist in Orthodontics for Children and Adults MEDICAL HISTORY DENTAL HISTORY PLEASE CHECK IF PATIENT HAS HAD: PLEASE CHECK IF PATIENT HAS HAD: [YES] [NO] [YES] [NO] [ ] [ ] LATEX ALLERGY [ ] [ ] METAL ALLERGY [ ] [ ] ANY INJURIES TO FACE, MOUTH, TEETH: ________________________ [ ] [ ] DRUG ALLERGY [ ] [ ] [ ] [ ] JOINT SWELLING [ ] [ ] MORE THAN AN AVERAGE AMOUNT OF TOOTH DECAY [ ] [ ] PROSTHETIC JOINTS [ ] [ ] ANY MISSING PERMANENT TEETH [ ] [ ] BONE DISORDERS [ ] [ ] ANY TEETH REMOVED BY EXTRACTION [ ] [ ] ARTHRITIS [ ] [ ] ANY EXTRA PERMANENT TEETH [ ] [ ] RHEUMATOID ARTHRITIS [ ] [ ] ANY DIFFICULTY CHEWING OR SWALLOWING [ ] [ ] LUPUS [ ] [ ] ANY PAIN OR CLICKING UPON OPENING MOUTH [ ] [ ] HEART TROUBLE [ ] [ ] REGULAR DENTAL VISITS [ ] [ ] HIGH OR LOW BLOOD PRESSURE [ ] [ ] MITRAL VALVE PROLAPSE [ ] [ ] PREVIOUS ORTHODONTIC TREATMENT [ ] [ ] A PREVIOUS ORTHODONTIC CONSULTATION: ____________________________________________________________ THUMB, FINGER, LIP SUCKING HABIT DATE OF LAST DENTAL VISIT: ___________________________ _____________ [ ] [ ] RHEUMATIC/SCARLET FEVER [ ] [ ] THYROID PROBLEMS [ ] [ ] DIABETES [ ] [ ] KIDNEY OR LIVER PROBLEMS [ ] [ ] TUBERCULOSIS HAVE YOU EVER TAKEN ANY OF THE FOLLOWING BISPHOSPHONATES MEDICATION: [ ] [ ] ANEMIA FOSAMAX(I.E., ALENDRONAT),ACTONEL(I.E.,RISEDRONATE),AREDIA [ ] [ ] PROLONGED BLEEDING (I.E., PAMIDRONATE), BONEFOS (I.E.,CLODRONATE OR TILUDRONATE), BONIVA [ ] [ ] BRAIN INJURY (I.E.,IBANDRONATE), DIDRONAL (I.E., ETIDRONATE), OSTAC (I.E., PAMIDRONATE), [ ] [ ] FAINTNESS OR DIZZINESS ZOMETA (I.E.,ZOLEDRONIC ACID). IF YES, PLEASE SPECIFY [ ] [ ] EPILEPSY _____________________________________________________ [ ] [ ] EARACHES OR FREQUENT HEADACHES COMMENTS: [ ] [ ] SINUS TROUBLE [ ] [ ] TONSILS REMOVED [ ] [ ] ADENOIDS REMOVED [ ] [ ] SORE THROATS [ ] [ ] COLD SORES/FEVER BLISTERS [ ] [ ] HEPATITIS [ ] [ ] HIV/AIDS [ ] [ ] HISTORY OF SMOKING [ ] [ ] EMOTIONAL PROBLEMS IS PATIENT CURRENTLY UNDER CARE OF A PHYSICIAN? [ ] [ ] [ ] [ ] PATIENT'S PRIMARY PHYSICIAN: [ ] [ ] _________________ ALLERGIES: __________________________________ ALLERGIES TO MEDICATIONS:_______________________ YEAR OF ORTHODONTIC TREATMENT: __________________________________________ APPROXIMATELY HOW MUCH HAS PATIENT GROWN IN LAST YEAR? ADOLESCENT FEMALES: HAS MENSTRUATION BEGUN? [ ] YES [ ] NO DATE [MONTH/YEAR]: LIST ANY DRUGS OR MEDICATIONS CURRENTLY BEING TAKEN: SERIOUS ILLNESSES OR SYNDROMES: REASON: PATIENT'S OTHER PHYSICIANS: To the best of my knowledge, the information given is complete and correct. I give permission to take x-rays, photographs, and study models to be taken. I understand that these x-rays, photographs, and study models may be used for scientific meetings, presentations, publications of a scientific nature, or for study groups with the purpose of furthering the art and science of orthodontics. I have read the Notice of Privacy Practices for Arizona Orthodontic Studio and understand a copy of this document is in my dental file. DATE SIGNATURE OF PATIENT OR PARENT OR GUARDIAN IF PATIENT IS A MINOR DATE SIGNATURE OF REVIEWING ORTHODONTIST By typing in your name, you are agreeing to a digital signature, and that all information is correct. 3 Send by Email Print Save Clear All Fields