Dental History - Shirck Orthodontics
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196 East Broad St., Suite B Pataskala, Ohio 43062 Phone: 740-927-0667 68 N. High Street, Building D New Albany, Ohio 43054 Phone: 614-855-9110 Medical History Information Date__________________ Patient Name_______________________________________Age__________Birthdate___________________ Street Address_______________________________________________________Male______ Female______ City_______________________________________________State_________________Zip________________ Fathers Name_________________________________ Mothers Name_________________________________ Home Phone__________________________________ Cell Phone____________________________________ Family Dentist____________________________________Family Physician_____________________________ How did you hear about our office?______________________________________________________ CHECK ANY OF THE FOLLOWING FOR WHICH THE PATIENT HAS BEEN TREATED HEART TROUBLE MITRAL VALVE PRO HEART MURMUR RHEUMATIC FEVER PHEUMONIA HIV/AIDS ANEMIA EPILEPSY ASTHMA FAINT/DIZZY ATTENTION DEFICIT DISORDER KIDNEY PROBLEMS ENDOCRINE PROBLEMS PROLONGED BLEEDING TUBERCULOSIS LIVER INVOLVEMENT HEPATITIS BLOOD DISORDERS DIABETES OTHER__________ Does patient have tendency to: Colds___ Sore Throats___ Ear Infections___ Cold Sores___ Have tonsils and adenoids been removed?_________ If yes, at what age?_______ List any medications being taken and reason for use_________________________________________________________________________________________________ LIST ANY ALLERGIES OR DRUG SENSITIVITY______________________________________________________________________________________________ Dental History Date of last cleaning_____________ Date of last X-rays_______________List any injuries to the face, mouth or teeth______________ _________________________________ Has patient ever sucked their thumb?________ if so listed age started and ended__________ Responsible Party Information Name_________________________________________ Relationship to Patient____________________________________ Address (if different from above)__________________________________________________________________________ Cell Phone_______________________ Work Phone__________________________SSN#____________________________ Email Address_________________________________________________________________________________________ Dental Insurance Company_____________________ Insurance ID number_________________________________________ Date of Birth___________________ Employer__________________________ Marital Status_________________________ Spouse Name___________________________________ Date of Birth_________________ SSN#______________________ Signature_______________________________________________ Date________________________________
