Welcome to the office of Drs. Cassinelli and Shanker
Our mission is to treat each individual with care, dignity and compassion, to base all treatment decisions on scientific knowledge, and to be evidence-based and patient-centered in all of our clinical care. Above all, our goal is to obtain excellence in all that we do.
About You Today’s Date______
Name ______
Last First MI
MR / MRS / MS / DR
I prefer to be called______○ Male ○ Female
Birth date______/______/______Age______
SS #______Ethnicity______
Home Address______APT/CONDO #
______
City State Zip
○Married ○Divorced ○Separated ○Single ○Widowed
Home #______Cell #______Cell Carrier______
Work #______Email______
Employer______
Employer’s Address______
Position______
From whom did you first hear of our office?______
Other family members seen by us?______
General Dentist Name______Physician Name______
Do you have orthodontic Insurance? ○YES ○NO
Spouse information
His/Her Name______
Employer______SS #______
Work #______Cell #______Cell Carrier______
Does your spouse have orthodontic Insurance? ○YES ○NO
Person Responsible for Account
Name______Relationship______
Billing Address______
(if different than home address) APT/CONDO #
______
CITY STATE ZIP
Home #______Cell #______
Employer______Position______
Work #______SS #______
I understand that I am responsible for payment of services rendered.
______
Signature of Responsible Party (In most cases Patient) Date
Emergency Contact
Name______Relationship______
Home #______Work # ______
Cell #______
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes. I authorize the dental staff to perform the necessary dental services that I may need.
______
Signature Date
PLEASE COMPLETE THE DENTAL INSURANCE INFORMATION FORM IF YOU HAVE DENTAL INSURANCE WHICH HAS ORTHODONTIC COVERAGE.
If this office accepts insurance, I hereby authorize and direct payment of the dental/orthodontic benefits directly to this office.
______
Signature of Primary Insurance Owner Date
______
Signature of Secondary Insurance Owner Date
Dental History
The answers to the following questions are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.
Yes No DK/U For the following questions mark Yes, No, or Don't Know/Understand.
______Does patient have difficulty following directions?
______Does patient have difficulty brushing his/her teeth conscientiously?
______Does patient have a strong gag reflex?
______Does patient have learning disabilities or need extra help with instructions?
______Is patient sensitive, self-conscious?
______Supernumerary (extra) or congenitally missing teeth?
______Permanent or "extra” teeth removed?
______Chipped or otherwise injured primary (baby) or permanent teeth?
______Periodontal "Gum problems" or treated for periodontal problems?
______Thumb, finger or sucking habit? Until age ______
______History of speech problems?
______Mouth breathing habit, snoring, difficulty in breathing?
______Any relative with similar tooth or jaw relationships?
______Has patient ever had a prior orthodontic examination or treatment?
If so, when/where? ______
______Would patient object to wearing orthodontic appliances (braces) should they be
recommended?
Date of most recent dental examination ______
How often does patient brush? ______Floss?______
What is the patient, parent or referral sources’ primary concern?
(What brought you here?)
______
______
Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment? If so please list: ______
Medical Alert Summary – Office Use Only
______
2
Forms and Documentations/Medical Demographic Adult pgs 1-3 of 4
Revised 01/10
Yes No DK/U (if yes please circle)
______Birth defects or hereditary problems?
______Rheumatoid or arthritic conditions?
______Endocrine or thyroid problems?
______Kidney problems?
______Diabetes?
______Cancer or been treated for a tumor?
______Stomach ulcer or hyperacidity?
______Polio, mono, tuberculosis, pneumonia?
______Problems of the immune system?
______AIDS or HIV positive?
______Sexually Transmitted Diseases?
______Hepatitis, jaundice or liver problem?
______Fainting spells, seizures, epilepsy or neurologic problem?
______Mental health or behavioral problem, including ADHD,
bipolar, Depression?
______Vision, hearing, tasting or speech difficulties?
______Loss of weight recently, poor appetite?
______Excessive bleeding, black and blue tendency, anemia or bleeding disorders?
______High or low blood pressure?
______Tires easily?
______Chest pain, shortness of breath or swelling ankles?
______Cardiovascular problem (heart trouble), heart murmur, heart attack, angina, coronary insufficiency, stroke, inborn heart defects or rheumatic heart? If yes please list:
______
______Is premedication required for
cardiovascular problem?
______Do you have a poor or altered diet?
______Frequent headaches, colds
or sore throats?
______Eye, ear, nose or throat condition?
______Hayfever, sinus
trouble, hives?
______Asthma?
Yes No DK/U (if yes please circle)
______Tonsil or adenoid conditions?
______Allergies or drug reactions?
______Known Drug Allergies.
______
______
______Are you taking medication,
nutrient supplements or
non-prescription medicine?
Please list them:
______
______
______Do you or have you taken a
Bisphophonate* drug?
______Does the patient currently
have or ever had a
substance abuse
problem?
______Operations? ______
______Hospitalized for:
______
______
______Other physical problems or symptoms?
______
______
______Being treated by another health care professional? For______
Date of latest physical exam?______
Weight______Height______
Any additional medical information we should be aware of that may impact treatment: ______
I have read and understand the above questions.
I will not hold my orthodontist or any member of his/her staff responsible for any errors or
omissions that I have made in the completion of this form. If there are any changes in my own medical condition/history or dental status I will so inform this practice.
______
Signature of patient Date
*Actonel, Boniva, Fosamax,Fosamax Plus D, Skelid, Didronel, Aredia, Zometa, or Bonefos
Forms and Documentations/Medical Demographic Adult pg 4 of 4
Revised 07/12