logo
PATIENT INFORMATION
Name : [text-9000]
Email Address : [email-788]
Date : [date-20001]
Date of Birth : [date-20003]
Age : [text-9003]
Sex : [text-9004]
School : [text-9005]
Grade : [text-9006]
Home Address : [text-9007]
City : [text-9008]
Postal Code : [text-9009]
Tel : [text-9010]
Number of Children in Family : [text-9011]
Age & Names of Other Children : [text-9012]
Patient’s Dentist : [text-9013]
Tel : [text-9014]
Family Physician : [text-9015]
Tel : [text-9016]
Who may we thank for referring you? : [text-9017]
Mother’s Name (if applicable) : [text-9018]
Home Tel : [text-9019]
Work Tel : [text-9020]
Father’s Name (if applicable) : [text-9021]
Home Tel : [text-9022]
Work Tel : [text-9023]
Person Responsible for Account : [text-9024]
Address : [text-9025]
City : [text-9026]
Postal Code : [text-9027]
Tel : [text-9028]
Do you have an insurance plan that covers orthodontic treatment? : [checkbox-1600]
I authorize York Mills Orthodontics to use the e-mail address provided above for the purpose of maintaining correspondence about office events, educational information relating to orthodontics and for appointment reminders and confirmations. : [checkbox-1709]
   
MEDICAL HISTORY -
HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?
Rheumatic Fever : [checkbox-1600]
Tuberculosis : [checkbox-1601]
Diabetes : [checkbox-1602]
Heart Murmur : [checkbox-1603]
H.I.V./A.I.D.S. : [checkbox-1604]
Kidney Disorder : [checkbox-1605]
Mitral Valve Prolapse : [checkbox-1606]
Hepatitis A, B, or C : [checkbox-1607]
Liver Disease : [checkbox-1608]
Heart Disease : [checkbox-1609]
Sexually Transmitted Diseases : [checkbox-1611]
Asthma : [checkbox-1612]
Artificial Heart Valve : [checkbox-1613]
Blood Disease : [checkbox-1614]
Arthritis : [checkbox-1615]
Artificial Joints : [checkbox-1616]
Prolonged Bleeding : [checkbox-1617]
Other : [text-9029]
If you responded YES to any of the above, please give pertinent information : [text-9030]
Is the child in good health? : [text-9031]
Does the child have any history of major illness and/or operations? : [text-9032]
List any drugs or medication now being taken: Please give reasons : [text-9033]
List any allergies or drug sensitivities : [text-9034]
Does the child have a tendency to colds? : [text-9035]
Sore Throats? : [text-9036]
Ear Infections? : [text-9037]
Have tonsils or adenoids been removed? : [text-9038]
at what age? : [text-9039]
Has the patient reached puberty? Girls-Has menstruation started? : [checkbox-1633]
Boys-Has voice changed yet? : [checkbox-1634]
 
 
DENTAL HISTORY
Has the child ever been treated for a jaw joint problem, including surgery? : [checkbox-1618]
Have there been any injuries to the face, mouth or teeth? : [checkbox-1619]
Has the child ever sucked his/her thumb or finger? : [checkbox-1620]
Does the child have any speech problems? : [checkbox-1621]
Does the child have frequent canker or cold sores? : [checkbox-1622]
Is the child a mouth breather?
While Asleep : [checkbox-1623]
While Awake : [checkbox-1624]
Have you been informed of any missing or extra permanent teeth? : [checkbox-1625]
Has the child ever had a previous orthodontic examination? : [checkbox-1626]
Is the child especially apprehensive toward dental visits? : [checkbox-1627]
Does the child want orthodontic treatment? : [checkbox-1631]
Has any other family member had braces or orthodontic treatments? : [checkbox-1632]
If yes, name of family member if treated in our office : [text-9040]
When did you last see your dentist? : [text-9041]
List any sports, hobbies or musical instrument : [text-9042]
Reason for orthodontic consultation : [text-9043]
INFORMED CONSENT
Today's Date : [date-20004]
Patient or Guardian Signature: :
IP : [_remote_ip]
Date/Time : [_date] [_time]