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
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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 ________________________________
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?
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?______________________________
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)