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(972) 221 - 2515
PATIENT FORMS
PATIENT LOGIN
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PATIENT INFORMATION - CHILD
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Date:
Patient's Name:
First Name
Last Name
Prefers to be called:
Mailing Address:
Address1
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Birth date:
Age:
Grade:
School:
Gender:
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Male
Female
Home phone:
Area Code
Phone First 3
Phone Last 4
Email:
Other family members treated here? If so, who?
Names & birth date of siblings:
How did you hear of Dr. McFarland?
RESPONSIBLE PARTY INFORMATION
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Father's name:
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Address:
Address1
Address 2
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Home phone:
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How long at this address:
Employer/occupation:
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Birth date:
Mother's name:
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Address:
Address1
Address 2
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Home phone:
How long at this address:
Employer/occupation:
Business phone:
Number of years employed:
Birth date:
INSURANCE INFORMATION
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Are you covered by orthodontic insurance?
Insurance ID:
If so, please provide the following information so we can verify your coverage:
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Insured's name:
Insurance Company:
Group number:
Local number:
Insurance company address:
Employer:
Insurance company phone:
Do you have dual coverage?
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Yes
No
If yes, please complete the following:
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Insured's name:
Insurance company:
Group number:
Insurance ID:
Insurance company address:
Employer:
Insurance company phone:
DENTIST INFORMATION
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Dentist's name:
Date of last visit:
Dentist's address:
Phone:
EMERGENCY INFORMATION
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Name of nearest living relative not living with you:
Phone:
Area Code
Phone First 3
Phone Last 4
Complete Address:
Address1
Address 2
City
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Zip
HEALTH HISTORY
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Is patient currently under physician's care? Reason:
Please check box if you now have or have had:
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Adenoids removed
AIDS
Allergies
Anemia
Arthritis
Artificial Heart Valve
Asthma
Bone disorders
Bruxing
Cancer treatment
Cardiac pacemaker
Congenital heart lesions
Chronic cough
Diabetes
Ear problems
Emotional problems
Endocrine problems
Epilepsy
Faintness/dizziness
Headaches (frequent)
Heart murmur
Heart trouble
Hepatitis
Herpes
High blood pressure
HTLV-III virus
Jaundice
Joint swelling
Kidney treatment
Organ transplant
Osteoporosis
Prolonged bleeding
Psychiatric treatment
Rheumatic fever
Scoliosis
Shortness of breath
Sinus trouble
Stroke
Swelling ankles
TMJ* (see below)
Thyroid problems
Tonsils removed
Tuberculosis
Venereal disease
Whiplash
Please check box if any answer is YES:
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Any injuries to face, mouth, teeth
Thumb, finger, lip sucking
Mouth-breathing when awake, asleep
Any missing permanent teeth?
Any extra permanent teeth?
Any teeth removed by extraction?
Is there a tongue-thrust problem?
Any speech problems?
Any pain or clicking on opening mouth?
Has an orthodontist been consulted previously?
Reason:
In your own words, why are you seeking orthodontic treatment?
List any other serious illnesses:
List any allergies:
TEMPORO-MANDIBULAR AND FACIAL PAIN QUESTIONNAIRE
*Please circle Y or N in every item in ALL categories below if you checked TMJ above.
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QUESTIONNAIRE #1
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Does your jaw make noise so that it bothers you or others?
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Y
N
Does your jaw get stuck so that you can't open it freely?
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Y
N
Does it hurt when you chew or open wide to take a big bite?
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Y
N
Do you have earaches or pain in front of the ears?
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Y
N
Do you have pain in face, cheeks, jaw, throat, or temples?
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Y
N
Are you able to open your mouth as far as you want to?
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Y
N
Do you suffer from frequent headaches?
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Y
N
Does your jaw "feel tired" after eating a big meal or dental visit?
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Y
N
Are you aware of an uncomfortable or bad bite?
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Y
N
QUESTIONNAIRE #2
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Are you aware that your teeth grind at night?
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Y
N
Do you have the habit of "clamping" or "setting" your teeth?
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Y
N
Do you have any jaw symptoms or headaches upon waking each morning?
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Y
N
Must you chew exclusively on one side?
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Y
N
Have you had a blow to the jaw? (trauma)
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Y
N
Are you a habitual gum chewer, pipe smoker, or nail biter?
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Y
N
QUESTIONNAIRE #3
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Does the pain or discomfort disturb your sleep?
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Y
N
Does the pain or discomfort interfere with your daily routine or other activities?
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Y
N
Do you take medication or pills for the pain or discomfort (pain relievers, muscle relaxants, antidepression pills)?
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Y
N
Des the pain or discomfort affect your appetite?
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Y
N
Do you find pain or discomfort extremely frustrating or depressing?
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Y
N
Briefly describe what the pain keeps you from doing:
QUESTIONNAIRE #4
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Do you suffer from arthritis or pain in the joints?
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Y
N
Do you suffer from nervous stomach or ulcers?
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Y
N
Do you suffer from colitis?
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Y
N
Do you suffer from back or neck pain (whiplash)?
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Y
N
Do you suffer from skin problems or allergies?
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Y
N
Have you ever been treated for a jaw, muscle, or joint disorder?
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Y
N
Are you "double jointed" in any of your joints?
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Y
N
Signature of parent or guardian
Date:
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