Microsoft word - adult patient form 2010 _ridgewood_

DR. NICOLE CLEMENTE ♦ DR. MARISSA CLEMENTE ♦ DR. MICHAEL CLEMENTE 60 W. RIDGEWOOD AVENUE RIDGEWOOD, NJ 07450 ♦ PHONE: (201-447-2888) ♦ E-MAIL: [email protected] Today’s Date: _____________________ Patient’s Name: __________________________________________________ Date of Birth: __________________________ Age: _________ Male: _________ Female: _________ Social Security Number: _________________________________ Home Address: _________________________________________________________________________________________ Home Phone #: ______________________________________ Cell Phone #: ______________________________________ E-mail Address: ______________________________________ Would you like to receive email confirmation? Y N Employer: _______________________________________________ Occupation: ____________________________ Business Address: _______________________________________________________________________________________ Work # ______________________________________________ MARITAL STATUS: Spouse’s name: _________________________________________________ Cell Phone # ___________________________ Employer: _______________________________________________ Occupation: ____________________________ Business Address: _______________________________________________________________________________________ Work # ______________________________________________ NAMES & AGES OF CHILDREN: _______________________________________________________________________ Names of other family members seen by us: ________________________________________________________________ WHO MAY WE THANK FOR REFERRING YOU? _________________________________________________________ Family Dentist: _________________________________________________________________________________________ Last Visit Date: ___________________________________ Office Phone #: _______________________________________ Address: _______________________________________________________________________________________________ Primary Insurance Insurance Co. Name: ____________________________________________________________________________________ Group #: ___________________________________________ Insurance Co. Phone #: ______________________________ Insurance Co. Address: __________________________________________________________________________________ Insured’s Name: ______________________________________________ Relationship: ____________________________ Insured’s Birthdate: _________________________________ Insured’s Social Security #: ___________________________ Insured’s Employer: _____________________________________________________________________________________ Secondary Insurance Insurance Co. Name: ____________________________________________________________________________________ Group #: ___________________________________________ Insurance Co. Phone #: ______________________________ Insurance Co. Address: __________________________________________________________________________________ Insured’s Name: ______________________________________________ Relationship: ____________________________ Insured’s Birthdate: _________________________________ Insured’s Social Security #: ___________________________ Insured’s Employer: _____________________________________________________________________________________ It is extremely imperative for your benefit, and others that you fill out this form completely. Thank you. Physician: ______________________________________________________________________________________________ Last Visit Date: ___________________________________ Office Phone #: _______________________________________ Address: _______________________________________________________________________________________________ Do Any Of The Following Apply To You? Y N Anemia Y N Epilepsy / Seizures / Fainting Spells Cardiac Conditions: Y N Congenital Heart Defects /Artificial Valves Y N Heart Murmur Y N Heart Surgery / Pacemaker Y N Heart Attack / Stroke Y N Mitral Valve Prolapse Y N Rheumatic / Scarlet Fever Respiratory Conditions: Y N Asthma Y N Allergies ( Latex / Medications / Food ) Please specify: ________________________________________________ Y N Emphysema Y N Sinus Problems Y N Tuberculosis Have you been hospitalized for any reason? Y N If yes, please describe: ___________________________________________________________________________________ Are you currently under care of a physician? Y N If yes, please describe: ___________________________________________________________________________________ Are you currently taking any medication(s) prescribed by a physician or dentist? Y N If yes, please describe: ___________________________________________________________________________________ To help us serve you better, are there any neurological/psychological/emotional/developmental conditions (Hypersensitivity, ADHD, ADD, Austism, Down Syndrome, etc…) that you would like us to know about? Y N If yes, please describe: ___________________________________________________________________________________ ________________________________________________________________________________________________________ HAVE YOU EVER TAKEN ANY OF THE BISPHOSPHONATE PREPARATIONS? ORAL Y N Fosamax Y N Boniva IV Y N Aredia Y N Zometa DO YOU HAVE ANY OF THE FOLLOWING CO-EXISTING RISK FACTORS? Y N Diabetes Y N Long term Steroid Use List & discuss any medical problems: _____________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ INFORMED CONSENT FOR BISPHOSPHONATE THERAPY Bisphosphonates are a class of compounds used for the treatment of many different medical conditions. These compounds localize to bone and inhibit osteoclast- mediated bone resorption. Since bisphosphonates are not metabolized, high concentrations are maintained within the bone for a long time. Successful orthodontic treatment depends on osteoclastic activity to allow tooth movement. Inhibition of tooth movement occurs to a greater degree with high IV doses than lower oral doses. The most serious dental side effect of bisphosphonate treatment (particularly when it is administered intravenously) is Osteonecrosis of the mandible or maxilla represented by exposed non-healing bone. Other related complications include decreased bone healing and inhibition of orthodontic tooth movement. By my signature below, I affirm that I have read this consent form, and have had the opportunity to ask questions. Also, unfamiliar terms have been explained to me. Patient Name: _______________________________________________________________________ Signature: __________________________________________ Have you ever experienced pain / discomfort in the jaw joint (TMJ)? Y N If YES, are you currently being treated? _________________________________________________________________ Have you ever experienced tenderness / pain in your jaw joint? Y N Have you ever experienced locking? ( Either open lock or closed lock) Y N Do you clench / grind teeth? Y N Any limitations in the range of movement? Y N Have there been any injuries to the: Face Mouth Teeth Chin If YES, please explain: _________________________________________________________________________________ Have you ever been diagnosed with Gingival (Gum) Disorder? Y N Do you need to be pre-medicated with an antibiotic prior to invasive dental procedures that will cause bleeding because of a heart problem? Y N Have you had previous orthodontic treatment? If YES, please explain: _________________________________________________________________________________ Have you consulted another orthodontist? Y N Do you have any other family member(s) that are currently being treated orthodontically? Y N If YES, please list and explain: _________________________________________________________________________ What are your concerns / reasons for desiring orthodontic treatment? _________________________________________ ________________________________________________________________________________________________________ I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my ( child’s ) status. I authorize the dental staff to perform any necessary dental services that I / my child may need during the diagnosis and treatment with my informed consent. ___________________________________________________

Source: http://clementeorthodontics.com/Portals/0/Adult%20Patient%20Form%202010%20(Ridgewood).pdf