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1005 N. Mechanic
El Campo, TX 77437
979-543-2411
Office hours:
Monday-Thursday
8:30-4:30
Corwin Orthodontics, El Campo, Victoria and Yoakum area Orthodontist
Confidential Adult Patient Health History & Information
Patient Information
Date
First Name
Middle Name
Last Name
Address
City
State
Zip Code
Birth Date
Age
Sex
Social Security No.
Home Phone
Work Phone
Cellular Phone
Phone number we should use to confirm appointments
Email address we can use to contact you
How did you hear about our office?
Employer
Occupation
Responsible Party Information
Name of person financially responsible for account
First Name
Middle Name
Last Name
Social Security Number
Birth date
Relationship to Patient
Address
City
State
Zip Code
Home Phone
Work Phone
Mobile Phone
Employer
Occupation
Do you have dental insurance which covers orthodontic treatment?
Billing information and/or any other correspondance should be sent to
Dental History
What is the main orthodontic problem as you see it?
Are you sensitive about the appearance of any facial features? (nose, chin, lips, etc.):
What do you consider the main benefits of orthodontic treatment?:
Cosmetic
Functional
Psychological/Emotional
Other
Have you ever had an orthodontic consultation?
If yes, when?
Have you ever had braces before? If Yes, when?:
Has anyone in the family received orthodontic treatment?:
If yes, who?:
What would you like orthodontic treatment to accomplish?:
Name of your general dentist
Frequency of dental exams
Date of last dental exam:
Please check all that apply, now or in the past
Yes - Discomfort from teeth
Yes - Previous orthodontic therapy
Yes - Teeth that are shifting
Yes - Frequent canker sores
Yes - Thumb/finger sucking as a child
Yes - Fluoride treatments
Yes - Any injuries to face, mouth, teeth
Yes - Speech therapy
Yes - Injury involving teeth
Yes - Injury to either jaw
Yes - Frequent clenching of teeth
Yes - Grinding of teeth
Yes - Wake up with sore teeth
Yes - Wake up with sore jaw
Yes - Jaw joint sounds
Yes - Jaw joint pain
Yes - Jaw “tires” when eating
Yes - Facial pain
Yes - Frequent headaches
Yes - Neck or shoulder pain
Yes - Tonsils/Adenoids removed
Yes - Any missing or extra permanent teeth
Yes - Any discomfort from gums
Yes - Requires premedication
Other
If you checked yes to any of the above, please explain
Medical History
Patient’s Physician
Approximate date of last physical
Is the patient currently in good physical health?
If no explain
Please check all that apply, now or in the past
Yes - Allergic to latex
Yes - Allergic to metals
Yes - Anemia/Radiation treatment
Yes - Arthritis
Yes - Asthma
Yes - Congenital heart defect
Yes - Diabetes
Yes - Ever been hospitalized
Yes - Heart attack/Stroke
Yes - Heart murmur
Yes - Hepatitis
Yes - Hormone therapy
Yes - Mouth breathing
Yes - Prolonged bleeding
Yes - Psychological counseling
Yes - Rheumatic fever
Yes - Seizures/Epilepsy
Yes - Taking medications
Yes - Tuberculosis
Yes - Drug allergies
Yes - Requires premedication
Other
If you checked yes to any of the above, please explain
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature Of Patient
Date

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