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Menu
NEW PATIENTS
MEET US
Open menu
Meet Dr. Shireen
Reviews
BRACES
Open menu
Types of braces
Life with braces
Braces for Children
Adult orthodontic treatment
Clear (Ceramic) braces
Two phase treatment
Braces FAQ
Emergency Care
INVISALIGN
Open menu
For adults
Invisalign Teen
CONTACT
CALL
contact
NEW PATIENTS
MEET US
Open menu
Meet Dr. Shireen
Reviews
BRACES
Open menu
Types of braces
Life with braces
Braces for Children
Adult orthodontic treatment
Clear (Ceramic) braces
Two phase treatment
Braces FAQ
Emergency Care
INVISALIGN
Open menu
For adults
Invisalign Teen
CONTACT
CALL
Menu
NEW PATIENTS
MEET US
Open menu
Meet Dr. Shireen
Reviews
BRACES
Open menu
Types of braces
Life with braces
Braces for Children
Adult orthodontic treatment
Clear (Ceramic) braces
Two phase treatment
Braces FAQ
Emergency Care
INVISALIGN
Open menu
For adults
Invisalign Teen
CONTACT
CALL
Health History Update
PATIENT INFORMATION - HEALTH HISTORY UPDATE
TITLE
Dr.
Mr.
Miss
Ms.
Mrs.
PATIENT FIRST NAME
(Required)
PATIENT LAST NAME
(Required)
PREFERRED NAME OR NICK NAME
DATE OF BIRTH
(Required)
Month
Day
Year
AGE
(Required)
GENDER
(Required)
MALE
FEMALE
PARENT OR GAURDIAN NAME - IF PATIENT UNDER 18
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
PRIMARY PHONE
(Required)
MOBILE PHONE
WORK PHONE
Email
(Required)
DENTIST NAME
(Required)
DATE LAST VISIT
Month
Day
Year
DENTAL HISTORY
CHECK ANY OF THE FOLLOWING DENTAL CONDITIONS
Blisters on lips / mouth
Grinding teeth
Jaw surgery
Periodontal surgery
Broken fillings
Gums bleeding
Lip/cheek biting
Sensitivity to hot or cold
Burning sensation, tongue
Gums sore / swollen
Loose teeth (other than baby teeth)
Sensitivity to sweets
Chews on tongue
Injuries to teeth / jaw
Mouth breathing
Sensitivity to pressure
Dry mouthInjuries to face/head
Mouth pain when
brushing
Sores / growths in mouth
Extracted teeth
Jaw clicking / popping
Orthodontic treatment
Speech problems
Finger / thumb habits
Jaw locking open / closed
Pain around ear
Tongue thrust
Food trapped between teeth
Jaw pain / tenderness
Periodontal treatment
HOW OFTEN DO YOU BRUSH?
HOW OFTEN DO YOU FLOSS?
ADDITIONAL COMMENTS
MEDICAL HISTORY - CHECK IF YOU CURRENTLY HAVE OR HAVE HAD ANY OF THE FOLLOWING:
CONDITIONS
AIDS
Chemotherapy
Hepatitis
Scarlet fever
Anemia
Circulatory problems
High blood pressure
Shortness of breath
Arthritis
Cortisone treatment
HIV Positive
Stroke
Artificial heart valves
Coughing - persistent
Kidney disease
Stomach ulcers
Artificial joints
Diabetes
Liver disease
Swelling of feet
Asthma
Epilepsy
Mitral valve prolapse
Thyroid problems
Back problems
Fainting
Nervous system problems
Tobacco habit
Blood diseases
Glaucoma
Pacemaker
Tonsillitis
Bone disorders
Headaches
Psychiatric Care
Tonsils removed
Cancer
Heart murmur
Radiation treatment
Tuberculosis
Chemical dependency
Heart problems
Respiratory disease
Urinary problems
Other (not listed)
DO YOU BELIEVE YOU MIGHT BE PREGNANT?
YES
NO
HOW FAR ALONG?
ARE YOU UNDER THE CARE OF A PHYSICIAN?
YES
NO
FOR WHAT CONDITION?
PHYSICIAN'S NAME
PHYSICIAN'S PHONE
MEDICATIONS AND ALLERGIES
PLEASE LIST ANY & ALL ALLERGIES YOU ARE AWARE OF
PLEASE LIST ANY & ALL MEDICATIONS THAT YOU CURRENTLY TAKE
PLEASE LIST ANY MEDICAL PROBLEMS THAT YOU'VE EXPERIENCED WITHIN THE LAST 5 YEARS (HYPERTENSION, DIABETES, SURGERY, ETC.)
DISCLOSURES AND AGREEMENTS
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment. It is my responsibility to inform this office of any changes in my personal information or health status. I will not hold mBrace Orthodontics or the staff responsible for any errors or omissions that I have made in the completion of this form.
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Dr. Shireen Irani and mBrace Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility and available upon request
Dr. Shireen Irani and mBrace Orthodontics reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices upon request.
NAME OF PATIENT OR PERSONAL REPRESENTATIVE
(Required)
First
Last
DESCRIPTION OF PERSONAL REPRESENTATIVE'S AUTHORITY