Patient Biographical Information
Last Name:
First Name:
Date of Birth:(mm/dd/yyyy)
Male
Female
Age:
Occupation:
Home Address:
City:
Province:
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code:
Home Phone:
Cell Phone:
Email:
Work Phone:
Person Responsible for Account:
Do you have dental insurance?
Yes
No
Unsure
If yes, please provide:
Policy Holder's Name:
Name of Insurance Company:
Group/Policy/Plan Number:
Policy Holder's Date of Birth (mm/dd/yyyy):
ID or Certificate Number:
Are you covered by any other dental insurance?
Yes
No
Unsure
If yes, please provide:
Policy Holder's Name:
Name of Insurance Company:
Group/Policy/Plan Number:
Policy Holder's Date of Birth:(mm/dd/yyyy)
ID or Certificate Number:
Family Dentist:
Family Physician:
Date of last visit:
Whom may we thank for referring you?
What is the reason for your visit?
Medical History
Yes
No
Are you in good health?
Yes
No
Have you had any serious illnesses/hospitaliztions?
Do you currently have or have you been treated for any of the following:
Rheumatic Fever
HIV/AIDS
Liver Disease
ADD/ADHD
Heart Murmur
Hepatitis A, B or C
Asthma
Autism
Mitral Valve Prolapse
S.T.D.
Arthritis
Nervous Disorders
Heart Disease
Blood Diseases
Bone Disorders
Fainting or Dizziness
Artificial Heart Valve
Prolonged Bleeding
Endocrine Problems
Frequent Headaches
Artificial Joints
Diabetes
Emotional Problems
Epilepsy
Tuberculosis
Kidney Disorder
Anxiety
Other (please specify below)
If you checked any of the above, please give details:
List any medications now being taken:
List any drug allergies or sensitivities:
Do you smoke or chew tobacco? How often?
WOMEN: Are you pregnant?
Yes
No
Dental History
Yes
No
Have you ever had any injuries to the face, mouth or teeth?
Yes
No
Have you ever been treated for a jaw joint problem, including surgery?
Yes
No
Have you ever sucked your thumb or finger? Until what age?
Yes
No
Do you have any speech problems?
Yes
No
Do you have any habits (nail biting, lip biting)?
Yes
No
Do you have frequent canker or cold sores?
Yes
No
Are you a mouth breather? While asleep? While awake?
Yes
No
Have you been informed of any missing or extra permanent teeth?
Yes
No
Do you grind or clench your teeth?
Yes
No
Do you have difficulty opening and/or closing your jaw?
Yes
No
Have you ever had a previous orthodontic examination?
Yes
No
Are you apprehensive towards dental visits?
Yes
No
Have any other family members had braces or orthodontic treatment?
How often do you brush your teeth?
How often do you floss?
I hereby give Dr. Nicholas Karaiskos, and/or members of his team, permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or other specialist as is deemed necessary from time to time. Such information includes radiographs (x-rays) and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment or treatment in progress. I also understand that my diagnostic records may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. I have read and understand this paragraph, and I authorize Dr. Nicholas Karaiskos to perform a complete orthodontic evaluation on me.