Title: MasterMsMrMrs

Date of Birth:

Surname:

First Name:

Email:

Home Address:

Post Code:

Telephone

Home:

Work:

Postal Address:

Mother's Name:

Father's Name:

Person Responsible for fees

Name:

Address:

Name of your Dentist

Name:

Address:

Who recommended that you seek a consultation here?

Have any other members of your family had orthodontic treatment?

Name of your Doctor

Name:

Address:

What aspect(s) of the arrangement of your teeth most concerns you?

If you answer "YES" to any questions below, please provide details in the space provided.

Have you had your teeth checked in the last 12 months?  Yes No

Have you been to see another orthodontist?  Yes No

Have you ever undergone orthodontic treatment in the past?  Yes No

Have your teeth or jaws ever been damaged in the accident?  Yes No

Do you ever suffer from pain, clicking, limitation of movement, or locking of your jaw joints?  Yes No

Have you ever had a serious medical or surgical problem?  Yes No

Are you currently taking medication?  Yes No

Do you have any allergies (Especially to drugs or medications)?  Yes No

Females: Are you pregnant?  Yes No

Do you suffer from (or have you ever had) any of the following?  Rheumatic Fever Heart Disease High Blood Pressure Stroke Diabetes Fits/Epilepsy Hepatitis Any Blood Disorders

Details of "YES" answers:

Do you have any reason to believe that you maybe in an "at risk group" for AIDS or Hepatitis B?  Yes No

If "YES", please advise the orthodontist at the consultation.