Thomas Orthodontics

Brian W. Thomas, D.M.D., M.S., P.A.

PATIENT INFORMATION
Todays Date _________________
Patient Name___________________________________________ Age________ Male_____ Female_____
Address_______________________________________________________________________________
Home Phone_______________ Cell Phone ____________________ E-mail ________________________
City__________________________________ State _____________ Zip Code______________________
School _______________________________ Grade _____________Birthday ______________________
Hobby or Interest__________________________________
Fathers name __________________________ Fathers place of employment ________________________
Fathers work address and number __________________________________________________________
Mothers name__________________________ Mothers place of employment _______________________
Mothers work address and number__________________________________________________________
Family dentist ___________________________Family physician _________________________________
Date of last dental checkup _______________________________________________________________
Reason for Orthodontic Exam_____________________________________________________________
How did you become acquainted with our office? ______________________________________________
_____________________________________________________________________________________
Have any other children in your family received orthodontic care? __________________________________
Medical Insurance Carrier ________________________________________________________________
Dental Insurance Carrier _________________________________________________________________
Responsible party Name___________________________ Relationship to patient _____________________
(if other than above)

Address __________________________________Phone _________________________

City ________________________________State___________ Zip Code ____________
Place of employment___________________________ Phone _____________________

2047 OSPREY LANE, SUITE D LUTZ, FL 33549

PHONE: (813) 948-9494
EMAIL: THOMASDMD@HOTMAIL.COM

MEDICAL HISTORY
THE

F O L L OW I N G Q U E S T I O N S H O U L D B E A N S W E R E D A B O U T T H E PA T I E N T B E I N G E X A M I N E D

Are you under the care of a medical doctor at the present time? If so, for what? ______________________
_____________________________________________________________________________________
Date and reason of your most recent visit to a physician _________________________________________
Are you allergic to any food, drug, or medicine? If so, what? _____________________________________
_____________________________________________________________________________________
Are you taking any pills, drugs or medicines at this time? If so, what? _______________________________
_____________________________________________________________________________________
PLEASE

C H E C K A N Y O F T H E F O L L OW I N G T H A T Y O U H AV E O R H AV E H A D T R E A T M E N T F O R
Yes

No

Year

Yes

No

Year

Adenoids Removed

____

High Blood Pressure

____

AIDS

____

HIV Positive

____

Allergies

____

Hyperactivity

____

Anemia

____

Kidney Disorder

____

Blood Disorder

____

Liver Disorder

____

Bone Disease

____

Lung Disorder

____

Breathing Difficulties

____

Pregnancy (women)

____

Bronchitis

____

Prolonged Bleeding

____

Convulsions

____

Rheumatic Fever

____

Diabetes

____

Seizures

____

Emotional Disturbance

____

Speech Difficulties

____

Epilepsy

____

Stroke

____

Eye Disorders

____

Tonsils Removed

____

Fainting Spells

____

Tuberculosis

____

Heart Condition

____

Tumor or Cancer

____

Hepatitis

____

Venereal Disease

____

Other_____________________________________________________________________________________________________
Please give details ___________________________________________________________________________________________

D E N TA L H I S T O RY
Injuries to the face, mouth or teeth

Yes

No

Pain (ear, jaw joint, side of face)

Yes

No

Missing any permanent teeth

Yes

No

Difficulty in opening or closing the jaw

Yes

No

Previous Orthodontic treatment

Yes

No

Fingernail biting

Yes

No

Oral Surgery

Yes

No

Clench or grind your teeth at night

Yes

No

Periodontal Treatment

Yes

No

Cheek or lip biting

Yes

No

Bite adjustment or teeth ground down

Yes

No

Pencil biting

Yes

No

Worn a bite plate or other appliance

Yes

No

Mouth Breathing

Yes

No

TMJ disorder

Yes

No

Do you snore?

Yes

No

Clicking of the Jaw

Yes

No

Do you have Headaches?

Yes

No

Please give details ___________________________________________________________________________________________

Reason for orthodontic exam __________________________________________________________________________________
Please describe any previous orthodontic treatment __________________________________________________________________

Signature _____________________________________________

Date ________________