New Patient Over 18 - Earlwood Orthodontics

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Dr Jimenez

Treatments

Age Groups

Early Treatment

Teenage Treatment

Adult Treatment

Treatment Options

Lightforce™ Clear Braces

Traditional Braces

Contact Us

Dentist Referrals

Patient Information

Patient Information

Financial Information

Private Health Cover

Knowledge Centre

Emergency Information

Contact Us

Dentist Referrals

Our Practice

About Us

Contact Us

Dentist Referrals

New Patient Over 18

Δ

1Patient Details

2Medical History

3Dental History

4Disclaimer

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This field is for validation purposes and should be left unchanged.

Patient Details

First Name*

Last Name*

Date of Birth*

DD slash MM slash YYYY

Gender*

Occupation

Address*

Address Address Line 2 City ZIP / Postal Code

Phone*

Email Address*

What prompted you to book a consultation with Earlwood Orthodontics?*

What are your concerns about your teeth?*

Do you have a particular appliance in mind, such as braces or clear aligners?*

Do you have any concerns about starting treatment?*

Do you have a private health fund with Orthodontic Cover?*

Yes

No

Before your orthodontic consultation, we recommend asking your health fund the following questions:

Is there a lifetime limit for orthodontics?
What is my annual limit for orthodontic claims?
Do I need to submit my claim before the end of the financial year?
Is there a deadline for claiming before the end of the calendar year?

Date of first appointment*

DD slash MM slash YYYY

Time of first appointment*

Hours

:

Minutes

AM/PM

Medical History

Doctor's Name*

Have you had or do you have any of the following?*

Please select the boxes that relate to you.

Rheumatic Fever

High Blood Pressure

Blood Vessel Disease

AIDS / HIV Infection

Kidney Trouble / Diabetes

Ulcers / Cold Sores / Herpes (any type)

Asthma

Mental Health Problems

Ear Disorder

Allergies

Heart Murmur

Heart Attack / Stroke

Blood Disorder / Anaemia

Hepatitis A, B or C

Gastric Problems

Persistent Head Aches / Migraine / Neck Pains

Nerve or Brain Disease

Bone Disorders

Sinus Infection

Cancer

None of the Above

Have you had any prosthetic surgery?*

ie. heart valves or hip replacements.

Yes

No

Are you presently, or have you ever been, under the care of a psychiatrist or psychologist?*

If yes, please describe.

Yes

No

Please describe your care under a psychiatrist or psychologist*

Are you allergic to any medications (e.g. aspirin, penicillin, etc)?*

If yes, what?

Yes

No

Please describe your allergies*

Have you ever had a general anaesthetic?*

If yes, when?

Yes

No

Please note when you had general anaesthetic*

Are you under a doctor’s care at present?*

If yes, please describe.

Yes

No

Please describe the care you are under with your doctor*

Are you currently taking any medication?*

If yes, please describe.

Yes

No

Please describe any medications you are currently taking*

Have you ever had your tonsils removed?*

If yes, when?

Yes

No

Please note when you had your tonsils removed*

Please note any other significant information about your medical history, including drug dependence.

Dental History

Dentist Name*

Date of Last Check Up*

Do you experience painful teeth?*

Please select the boxes that relate to you.

No

Yes

Upper right

Upper left

Lower right

Lower left

Have you experienced any of the following?*

Please select the boxes that relate to you.

Wisdom teeth removed

Injuries in the head and neck area

Surgery in the head and neck area

Noticed soreness, tightness or pain in the muscles around the jaws/ face

Treatment for periodontal disease (gum disease)

Fallen and bumped your chin, or received a blow to the jaws

Clenching or grinding of your teeth

Pain when chewing

None of the above

Do you hear clicking (popping) or grating sounds in the jaw joints?*

Clicking

Grating

Both

No

Describe Clicking

Clicking

Left

Right

Both

Clicking

Began Gradually

Began Suddenly

Clicking Since When?

Clicking During What Activity?

Describe Grating

Grating

Left

Right

Both

Grating

Began Gradually

Began Suddenly

Grating Since When?

Grating During What Activity?

Was there some specific event that started the joint sounds?*

If yes, please describe.

Yes

No

Please describe the event that started the joint sound*

Have you ever experienced difficulty in opening or closing your jaws, or “locking” of the jaws open or closed?*

If yes, please describe.

Yes

No

Please describe the difficulty in opening or closing your jaws, or “locking” of the jaws open or closed*

Have you had pain in your jaw joints?*

Yes

No

Describe Jaw Joint Pain

Jaw Joint Pain

Left

Right

Both

Jaw Joint Pain

Began Gradually

Began Suddenly

Jaw Joint Pain Since When?

Jaw Joint Pain During What Activity?

What Increase the Pain?

What Decreases the Pain?

Do you have or have you had any of the following habits?*

Finger / Thumb sucking

Lip biting

Nail Biting

No

Has any other member of your family been a patient of this practice?*

If yes, please provide their name.

Yes

No

Family Member Name*

Have you had previous orthodontic treatment?*

If yes, please provide details.

Yes

No

When Did You Have Orthodontic Treatment?

Name of Orthodontist

Have you ever been treated for this problem before?*

If yes, please describe the diagnosis and treatment.

Yes

No

Diagnosis and Treatment

Disclaimer

Consent*

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 my clinical history, I recognise that it is my responsibility to inform this office. I also give my permission for a clinical examination and agree to take responsibility for associated fees.

I agree.

Signature*

Email

info@earlwoodorthodontics.com.au

Phone

Address

218 Homer St
Earlwood NSW 2206

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