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New Patient Questionnaires

For Children

New Patient Questionnaire (Child)

Patient Details-

Full Name: Birthdate: (yyyy-mm-dd)
Address: Postcode:
Phone: (Home) Phone: (Mobile)
Email:
School/College:
Name of Referrer:
Who recommended you to this practice?
Usual Dentist: (Name and Suburb)
Other members of family who have attended this orthodontic practice:




Parent's Details-

Mum's Full Name: Phone:
Dad's Full Name: Phone:

Billing Details (who is responsible for accounts) -

Full Name: Dr Mr Mrs Ms Miss Phone:
Address:




Medical History



List any serious illnesses or allergies e.g Heart conditions, bleeding disorders, diabetes, epilepsy, asthma, etc:



Are you taking any medications?



Are you at present receiving medical attention?



Have you had, or has it ever been recommended you have your tonsils and/or adenoids removed?




Dental & Orthodontic History

Have you had any serious injuries to your teeth or jaws?



Have you had any jaw pain, problems or clicks?



Have you had any teeth with deep fillings, root canal therapy or any teeth that your dentist is particularly concerned about?



Are you a mouth breather?



Do you or did you ever such your thumb or fingers after the age of 6?



Have you had, or has it been recommended that you have speech therapy?



Have you had, any previous orthodontic treatment or consultation?



What is your reason for seeking orthodontic treatment?





Please indicate the patient's concern for correction of orthodontic concerns?

 Very concerned Concerned Indifferent Opposed

Please indicate the parent's concern for correction of orthodontic concerns?

 Very concerned Concerned Indifferent Opposed

For Adults

New Patient Questionnaire (Adult)

Patient Details-

Full Name: Birthdate: (yyyy-mm-dd)
Address: Postcode:
Phone: (Home) Phone: (Mobile)
Email:
Occupation:
Name of Referrer:
Who recommended you to this practice?
Usual Dentist: (Name and Suburb)
Other members of family who have attended this orthodontic practice:




Billing Details (who is responsible for accounts) -

Full Name: Dr Mr Mrs Ms Miss Phone:
Address:




Medical History



List any serious illnesses or allergies e.g Heart conditions, bleeding disorders, diabetes, epilepsy, asthma, etc:



Are you taking any medications?



Are you at present receiving medical attention?



Are you pregnant or possibly pregnant?




Dental & Orthodontic History

Have you had any serious injuries to your teeth or jaws?



Have you had any jaw pain, problems or clicks?



Have you had any teeth with deep fillings, root canal therapy or any teeth that your dentist is particularly concerned about?



Are you a mouth breather?



Have you had, any previous orthodontic treatment or consultation?



What is your reason for seeking orthodontic treatment?





Please indicate your concern for correction of orthodontic problems?

 Very concerned Concerned Indifferent Opposed