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Patient's Last name First name Middle initial Home address City, State, Zip code ________________________________ Email Address: __________________________________________________________________________________ What concerns do you have about your teeth? How do you feel about orthodontic treatment? Who suggested that you might need orthodontic treatment? Describe any previous orthodontic treatment or consultations. Does the patient have any siblings? What are their names and ages? Have any other family members had Orthodontic Treatment? Favorite hobbies and activities? _________________________________________ Other dentists/dental specialists now being seen: Name City, State Most recent physical exam Other physicians/health care providers being seen now: Who will be responsible for bringing the patient to appointments? Relationship ____________ Preferred method of follow-up and appointment reminders? Please list anyone else who wil be involved in the patient’s care. Home Phone: ( ) - Cell phone ( ) - Work phone ( ) - Home Phone: ( ) - Cell phone ( ) - Work phone ( ) - Who is financially responsible for this patient? Birthday - - Home phone ( ) - Cell phone ( ) - Cel Phone Carrier Primary policy holder’s full name Birth date Social Security # - - Relationship to patient Does this policy have orthodontic benefits? Secondary policy holder’s full name Birth date Social Security # - - Relationship to patient Does this policy have orthodontic benefits? Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Has the patient been treated by a physician for: yes Birth defects or hereditary problems? yes Any teeth treated with root canals or pulpotomies? yes Cancer, tumor, radiation treatment or chemotherapy? yes Frequent canker sores or cold sores? yes History of speech problems or speech therapy? yes Mouth breathing habit or snoring at night? yes Frequent oral habits (sucking finger, chewing pen, etc.)? yes Gonorrhea, syphilis, herpes, sexual y transmitted diseases? yes Teeth causing irritation to lip, cheek or gums? yes Hepatitis, jaundice or other liver problems? yes Polio, mononucleosis, tuberculosis, pneumonia? yes Soreness in jaw muscles or face muscles? yes Seizures, fainting spells, neurologic problem? yes Been treated for “TMJ” or “TMD” problems? yes Mental health disturbance or depression? yes Any serious trouble associated with previous dental treatment? yes History of eating disorder (anorexia, bulimia)? yes Been diagnosed with gum disease or pyorrhea? yes Excessive bleeding or bruising tendency, anemia? yes Heart defects, heart murmur, rheumatic heart disease? yes Vision, hearing, or speech problems? yes Frequent ear infections, colds, throat infections? yes Ever taken bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer? Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone Now or in the past, has the patient had: yes Erupting teeth very early or very late? yes Supernumerary (extra) or congenital y missing teeth? yes Chipped or injured primary or permanent teeth? List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements taken by the patient. Have the parents or siblings ever had any of the fol owing health problems? If so, please explain. I authorize release of any information regarding patient orthodontic treatment to my dental and/or medical insurance company. I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my or my child’s medical or dental health.
Patient/Guardian Signature __________________________________________


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Stephen J. Kohut Psychopharmacology Laboratory Department of Psychology American University 4400 Massachusetts Ave, NW Washington, DC 20016 Phone: 202-885-1721 EDUCATION American University , Washington, D.C. Doctoral Candidate (Behavior, Cognition, and Neuroscience) Advisor: Anthony L. Riley Loyola College in Maryland , Baltimore, MD M.S. in Clinical Psychology, September 2005

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