MEDICAL HISTORY - Orthodontist Florence Cheraw Marion SC



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Sam H. Arazie, D.M.D., M.S.D., P.A.

Welcome to Our Office

Adult Orthodontic Acquaintance Card

Date___________ 20____

Patient’s name_________________________________________________ Age______ Sex: Male □ Female □

First Middle Last

Name Patient Prefers to be called_________________________________________________________________

Address__________________________________________________________Home Phone________________

Street City State Zip Cell Phone__________________

Martial Status: Married □ Single □ Divorced □ Social Security No.___________________________

Occupation___________________________________Employer________________________________________

Business Address ____________________________________________Work Phone_______________________

Spouse’s Name_______________________________________________________________________________

Occupation______________________________________Employer_______________________________

Business Address__________________________________________Work Phone

Name of Person Responsible for Account if other than yourself__________________________________________

Do you have dental insurance that covers orthodontic treatment? Yes □ No □

Dentist____________________________________________ Physician_________________________________

Last visit to Dentist____________________________________________________________________________

Is there someone other than your dentist that we may thank for referring you to our office?

(friends, neighbors, patients, etc.?)_____________________________________________________________

MEDICAL HISTORY

Are you in good health? Yes □ No □ History of Major Illness? Yes □ No □

Are you presently under the care of a physician for a specific problem? Yes □ No □

If so, please explain__________________________________________________________________________

PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS THAT YOU HAVE HAD OR CURRENTLY HAVE

Abnormal bleeding/Hemophilia Diabetes Hepatitis/Liver problems Pneumonia

Anemia Dizziness Herpes Prolonged Bleeding

Arthritis Epilepsy High Blood Pressure Radiation/Chemotherapy

Asthma or Hay Fever Gastrointestinal Disorders HIV / Aids Rheumatic Fever

Bone Disorders Heart Problems Kidney problems Tuberculosis

Congenital Heart Defect Heart Murmur Nervous Disorders Tumor or Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of?

____________________________________________________________________________________________________

List Any Medicines Now Being Taken. Give Reasons._________________________________________________________

____________________________________________________________________________________________________

List Any Allergies or Drug Sensitivities._____________________________________________________________________

____________________________________________________________________________________________________

DENTAL HISTORY

Have you ever had gum disease? ____________________________________________________ Yes □ No □

Has an orthodontist been consulted previously?_________________________________________ Yes □ No □

Have you had any previous orthodontic treatment?_______________________________________ Yes □ No □

If so, by whom?___________________________________________________________________

Do you have an unusual amount of stress in your life?____________________________________ Yes □ No □

Reason for seeking orthodontic treatment; What problem do you wish to have corrected? ____________________

___________________________________________________________________________________________

Please list any additional information which you feel might be helpful.____________________________________

___________________________________________________________________________________________

THANK YOU

Patient’s Signature: Date:

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Member

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