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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