BIGGS-HANSEN ORTHODONTICS www.indyortho.com

Jeffery Biggs, DDS, MS Vincent Hansen, DMD, MSD 9333 North Meridian Street, Suite 301, Indianapolis, IN 46260

Phone #: (317) 846-1455 E-mail: braces@indyortho.com Fax #: (317) 843-0626

Orthodontics and Temporomandibular Joint Disorders

Clinical History/Family Information (Please complete in ink)

Patient’s Name _____________________________________________________ Age______ Gender______ Birth Date_______________ Last First M.I.

Address _________________________________________________________________________________________________________ Street City State Zip

School ______________________________________________________ Grade ___________________________________________

Preferred phone number to call for appointments (During Business Hours) _________________________________________

Preferred E-mail Address _____________________________________________________________________________________

Father’s Name ________________________________________________ SS#____________________ Birth Date_____________ Last First M.I. (for accounting purposes only)

Marital Status: Single Married Separated Divorced Widowed Partnered

Home Address ___________________________________________________________________ Home Tel. # _______________

Street City State Zip Employed by _________________________________________ Occupation ____________________ Position ____________________

Office Address ____________________________________________________________________ Work Tel. # _______________

Orthodontic Insurance? Yes No Name of Insurance Company __________________ ID# ___________ Group #__________ Medical Insurance? Yes No Name of Insurance Company __________________ ID# ____________ Group # __________

Mother’s Name ________________________________________________ SS#____________________ Birth Date_____________ Last First M.I. (for accounting purposes only)

Marital Status: Single Married Separated Divorced Widowed Partnered

Home Address ___________________________________________________________________ Home Tel. # _______________

Street City State Zip Employed by _________________________________________ Occupation ____________________ Position ____________________

Office Address ____________________________________________________________________ Work Tel. # ______________Orthodontic Insurance? Yes No Name of Insurance Company ____________________ ID# ________ Group#___________ Medical Insurance? Yes No Name of Insurance Company _____________________ID# ________ Group#___________

Patient's Family Dentist ______________________________________________________________________________________

Patient's Family Physician _____________________________________________________________________________________ Whom may we thank for referring you to our office? ___________________________________________________________________

Responsible Party (if other than the patient’ s parents): Is Responsible Party authorized to sign consent on behalf of patient? Yes No

Name ________________________________ SS# _______________ Birth Date _______________ Relationship to patient ____________

Home Address _________________________________________________________________________ Tel. # ___________ Orthodontic Insurance? Yes No Name of Insurance Company ______________________ID# _________ Group # _________ Medical Insurance? Yes No Name of Insurance Company _____________________ _ID# _________ Group #_________

Child’s

https://get.adobe.com/reader/Please note: The newest free version of Adobe Acrobat Reader is needed to complete this form. Go to

MEDICAL HISTORY: Has the patient had, or does the patient have, any of the following?

Yes / No Yes / No Rheumatic Fever Heart Murmur High Blood Pressure Heart Attack/Stroke Blood Vessel Disease Blood Disorder AIDS/HIV Infection Hepatitis Diabetes Ulcers Herpes (Any type) Psoriasis Cancer

Persistent Headaches Neck Pains Nerve or Brain Disease Migraine Epilepsy Mental Health Problems Bone Disorders Arthritis (Any type) Artificial Joints Sleep Apnea Ear Disorder Sinus Infection Swollen Glands Allergies

Comments

Please list any other signi ant information about the patient’s medical history:

Yes No Is the patient under a physician’s care at present? If yes, reason Is the patient presently, or has patient ever been, under the care of a psychiatrist or psychologist? If yes, describe Is the patient currently taking any medications? If yes, describe Is the patient allergic to any medications? (e.g.: aspirin, penicillin, etc.) If yes, Has the patient ever had any general anesthesia? When?

DENTAL HISTORY: Yes No

Do any of the patient’s teeth hurt? If yes, upper right upper left lower right lower left Has the patient had any wisdom teeth removed? How many?

Has the patient ever had treatment for a periodontal disease (gum disease)? If yes, describe Has the patient ever had any previous orthodontic treatment (braces)? If yes, when If yes, doctor’s name and address

Have there been any injuries to the patient’s mouth or teeth? If yes, describe Has the patient ever had any injury in the head and neck area? If yes, describe

Has the patient ever fallen and bumped his/her chin, or received a blow to the jaws? If yes, describe

Has the patient ever had any surgery in the head and neck area? If yes, describe

Does the patient clench or grind his/her teeth? If yes, while sleeping under stress other_____________ Do the patient’s jaw muscles ever feel tired? If yes, when ____

Does the patient ever notice soreness, tightness or pain in the muscles around the jaws and face? If yes, describe _____________________________________________________________________________

Does it hurt to chew? If yes, where does it hurt? Does the patient hear clicking (popping) or grating sounds in his/her jaw joints? If yes, please describe:

Right Left Since when During what activity Clicking: Grating:

Did these joint sounds begin gradually or suddenly? gradually suddenly Was there some specific event that started the joint sounds? If yes, describe

Yes No

Does the patient have pain in his/her jaw joints? If yes Right Left Since when? ______________________ Did the pain start gradually or suddenly? gradually suddenly During what activity? Describe nature of pain What increases the pain? What decreases the pain?

Does the patient have any of the following habits? Yes No

Finger/Thumb Sucking Lip Biting Nail Biting Gum Chewing Ice Chewing

GROWTH AND DEVELOPMENT

Has the patient reached adolescent growth? Girls -Has monthly cycle started yet? If so, when Boys - Has voice changed yet? If so, when Is the patient adopted? Does the patient know? Yes No Are there any learning disabilities? If yes, explain

Are there other children in the family? Names and ages

Have any other members of the family had orthodontic treatment?

Have any other members of the family been patients in this office?

Name

Please describe why you sought this consultation ___________________________________________________________ Has the patient ever been treated for this problem before? If yes, please describe the diagnosis and treatment

Any information you can give us concerning your child will be appreciated. The more we know about each patient, the better we can manage the orthodontic treatment, both at home and in the office. Also, please include special interests and hobbies: ____________________________________________________________________________________________________

____________________________________________________________________________________________________ I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.

(Signature of Responsible Adult) Date

Orthodontist’s Notes

(Orthodontist’s Signature) Date

Has the patient ever experienced difficulty in opening or closing his/her jaws? If yes, describe Have the patient’s jaws ever “locked” closed or wide open? If yes, describe________________________