Tooth Fairy Dental on Eglinton
Orthodontic Intake Form - Adult
161 Eglinton Ave E, Unit 1, Toronto, ON M4P 1J5
416-546-9870
Welcome to Tooth Fairy Dental on Eglinton
Personal Information
Patient's Name:
Patient's E-mail:
Patient's D.O.B.
Age:
Gender Identity
Female
Male
Street:
City:
Province:
Postal Code:
Tel. Home:
Tel. Cell:
Patient's Dentist:
Last Appointment Date:
Patient's Physician:
Physician's Tel:
Patient's Occupation:
Person Responsible for the Account:
Relationship:
Is the Patient Covered by Orthodontic Insurance?
Yes
No
Emergency Contact:
Phone Number:
Medical History
Have you been treated for any of the following?
Yes
No
Yes
No
Frequent Colds
Leukemia/Cancer
ADD / ADHD
Tuberculosis
Rheumatic Fever
Endocrine Problems
Autism Spectrum
Asthma
Heart Murmur/Heart Disease
H.I.V. / A.I.D.S.
Emotional Disorder
Tonsillitis
Prolonged Bleeding/Blood Disease
Hepatitis A, B, or C
Artificial Heart Valve
Adenoids
Learning/Behavioral Condition
Diabetes
Eczema
Other
Liver Disease/Jaundice
Epilepsy
Vision Problems
Kidney Disease
Bone Disorders
Mouth-breathing
If you checked off any of the above please give pertinent details:
Are you currently being treated for any medical conditions?
Yes
No
Not Sure / Maybe
If yes, please explain:
List any drugs or medications being taken (Please give reason):
Do you have any history or major illness and/or operations?
Yes
No
Not Sure / Maybe
If yes, please explain:
List any allergies or drug sensitivities:
Have tonsils or adenoids been removed? If so at what age?
Do you have a tendency to cold sores, sore throats, or ear infections? (Please list):
Dental History
Have you ever been treated for a jaw joint problem, including surgery?
Yes
No
Have there been any injuries to the face, mouth, teeth?
Yes
No
If yes, please describe:
Have you had a history of thumb-sucking or finger-sucking?
Yes
No
If yes, age stopped:
Do you have any speech problems?
Yes
No
Are you a mouth-breather?
Yes
No
Have you consulted an orthodontist previously?
Yes
No
Have you had any previous orthodontic treatment?
Yes
No
If yes, please clarify:
Please check if there is a history of:
Yes
No
Yes
No
Clenching teeth
Headaches (more than normal)
Jaw joint popping
Jaw joint soreness
Grinding teeth
Muscular soreness around head and neck
Ringing in ears
Jaw joint clicking
Is there other information that may be helpful?
Reason for this orthodontic consultation:
I hereby give members of the staff permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment plan in progress.
I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.
Signature
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