Patient Questionnaire Sleep Apnea - Biggs-Hansen Orthodontics

The Center for Pediatric Sleep Apnea Orthodontics

www.indysleeportho.com
Jeffery Biggs, DDS, MS Vincent Hansen, DMD, MSD
9333 North Meridian Street, Suite 301, Indianapolis, IN 46260
Phone #: (317) 574-6483 E-mail: info@indysleeportho.com Fax #: (317) 843-0626
Child's Clinical History/Family Information
Patient's Name*

First NameM.ILast Name
Age*
Sex at Birth*
Patient's Date Of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Best # to Call*
Please enter a valid phone number.Format: (000) 000-0000.
Who's Phone Number
School*
Grade*
Preferred Email Address*
example@example.com
Father's Information
Name*

First NameM.ILast Name
Date Of Birth*

MonthDayYear
Date
SSN (for accounting purposes only)*
Marital Status*

SingleMarriedSeparatedDivorcedWidowedPartnered
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Employed By
Occupation
Position
Office Address

Street Address

Street Address Line 2

CityState

Zip Code
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Orthodontic Insurance?*

YesNo
Name of Insurance CO
ID#
Group #
Medical Insurance?*

YesNo
Name of Insurance CO
ID#
Group #
Please upload a picture of your dental insurance card here.
Insurance Card Front

Cancelof
Insurance Card Back

Cancelof
Mother's Information
Name*

First NameM.I.Last Name
Date Of Birth*

MonthDayYear
Date
SSN (for accounting purposes only)*
Marital Status*

SingleMarriedSeparatedDivorcedWidowedPartnered
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Employed By
Occupation
Position
Office Address

Street Address

Street Address Line 2

CityState

Zip Code
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Orthodontic Insurance?*

YesNo
Name of Insurance CO
ID#
Group #
Medical Insurance?*

YesNo
Name of Insurance CO
ID#
Group #
Reponsible Party (if other than the patient/spouse):*

YesNo
Please upload pictures of your dental insurance card if applicable:
Back of Card

Cancelof
Front of Card

Cancelof
Patient's Family Dentist*
Patient's Family Physician*
Whom may we thank for referring you to our office?*
MEDICAL HISTORY
Has the patient had or does the patient have any of the following? (check all that apply)*

Rheumatic FeverHeart MurmurHigh Blood PressureHeart Attack/StrokeBlood Vessel DiseaseBlood DisorderAIDS/HIV InfectionHepatitisDiabetesUlcersHerpes (Any type)PsoriasisCancerPersistent HeadachesNeck PainsNerve or Brain DiseaseMigraineEpilepsyMental Health ProblemsBone DisordersArthritis (Any type)Artificial JointsSleep ApneaEar DisorderSinus InfectionSwollen GlandsAllergiesNone
Comments
Please list any other significant information about the patient's medical history:
Is the patient under a physician's care at present?*

YesNo
If yes, reason
Is the patient presently under the care of a psychiatrist or psychologist?*

YesNo
If yes, reason
Is the patient currently taking any medication?*

YesNo
If yes, describe
Is the patient allergic to any medications? (e,g: aspirin, penicillin, etc.)*

YesNo
If yes, describe
Has the patient ever had any general anesthesia?*

YesNo
If yes, describe
Dental History
Please check all that apply*

Do your teeth hurt?Have any wisdom teeth removedPeriodontal disease / gum diseaseInjuries to your mouth or teethInjury in head/neck areaFallen and bumped chin/received a blow to your jawHead/neck area surgeryClench/grind teethJaw muscles feel tiredNotice soreness, tightness or pain in muscles around the jaws and faceHurts to chewHear clicking/popping or grating sounds in your jaw jointsExperienced difficulty in opening or closing your jawsJaws “locked” closedJaws “locked” wide openPain in your jaw jointsHad previous orthodontic treatmentNone
Please explain any checked answers
If yes,

Upper rightUpper LeftLower RightLower Left
Do you have any of the following habits?

Finger/Thumb SuckingLip BitingNail BitingGum ChewingIce Chewing
Has the patient reached adolescent growth?*

YesNo
Girls -Has monthly cycle started yet?

YesNo
If so, when
Boys - Has voice changed yet?

YesNo
If so, when
Is the patient adopted?*

YesNo
Does the patient know?

YesNo
Are there any learning disabilities?

YesNo
If yes, explain
Please describe why you sought this consultation
Has the patient ever been treated for this problem before?

YesNo
If yes, please describe the diagnosis and treatment:
Have any other members of the family had orthodontic treatment?

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

YesNo
Names?
Are there other children in the family?

YesNo
Names and ages
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:
HIPAA Notice of Privacy Practices
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.
Patient/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Office Use Only:
I have reviewed the information contained within this packet.
Patient Coordinator Notes
Orthodontist's Name

First NameLast Name
Orthodontist's Signature

Clear
Date

MonthDayYear
Date
Orthodontist's Notes
Received and reviewed
Should be Empty:

The Center for Pediatric Sleep Apnea Orthodontics

Child's Clinical History/Family Information

Father's Information

Please upload a picture of your dental insurance card here.

Mother's Information

Please upload pictures of your dental insurance card if applicable:

MEDICAL HISTORY

Dental History

Office Use Only: