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About Dr. Damas
Our Staff
Appointments & Scheduling
Your First Visit
Financial & Insurance
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Treatment
How Treatment Works
Right Age for Orthodontics
Your First Days in Braces
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Choose Your Look
Common Orthodontic Problems
Patient Education
Care & Use
Orthodontic Emergencies
Oral Hygiene
Retention
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Before and After
Photo Gallery
Invisalign
Invisalign
Invisalign Teen
Why Invisalign
The Invisalign Process
Caring for Invisalign
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Office & Contact Information
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Appointment Scheduling
Refer A Friend
ORLAND PARK (708) 349-1740
info@damasorthodontics.com
Home
About Us
About Dr. Damas
Our Staff
Appointments & Scheduling
Your First Visit
Financial & Insurance
Office Contests
Treatment
How Treatment Works
Right Age for Orthodontics
Your First Days in Braces
Propel Technology
Choose Your Look
Common Orthodontic Problems
Patient Education
Care & Use
Orthodontic Emergencies
Oral Hygiene
Retention
Photo Gallery
Before and After
Photo Gallery
Invisalign
Invisalign
Invisalign Teen
Why Invisalign
The Invisalign Process
Caring for Invisalign
Contact Us
Office & Contact Information
New Patient Forms
Appointment Scheduling
Refer A Friend
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CONSULTATION »
Confidential Adult Patient Health History & Information
Patient Information
Date
Last
First
Middle
Address (Street, City, State, Zip)
Nickname
Birth Date
Age
Gender
Male
Female
SSN#
Home Phone
Work Phone
Mobile Phone
Email address we can use for appointment reminders
Whom may we thank for referring you to our office?
Employer
Occupation
# of years employed
Hobbies / interest
Insurance Information
Policy Holder
Last
First
Middle
#SSN
Insurance Company
ID Number
Union Local Number
Insurance Address
Insurance Phone #
Policy Holder's Employer
Do You Have Dual Coverage?
Yes
No
If yes, please fill out the following
Policy Holder
Last
First
Middle
#SSN
Insurance Company
ID Number
Union Local Number
Insurance Address
Insurance Phone #
Policy Holder's Employer
Responsible Party Information
Name of person financially responsible for account:
Last
First
Middle
SSN#
Birth Date
Relationship to Patient
Address (Street, City, State, Zip)
Home Phone
Work Phone
Mobile Phone
Employer
Occupation
Do you have dental insurance which covers orthodontics?
Yes
No
Correspondence should be sent to:
Patient's Address
Financially Responsible's Address
Dental History
What is the main orthodontic problem as you see it?
Are you sensitive about the appearance of your teeth?
Are you sensitive about the appearance of any facial features? (nose, chin, lips, etc.)
What do you consider the main benefits of orthodontic treatment?
Cosmetic
Yes
No
Functional
Yes
No
Psychological/Emotional
Yes
No
Other
Yes
No
How do you feel about wearing braces?
Have you ever had an orthodontic consultation:
Yes
No
If yes, when?
Have you ever had braces before? If Yes, when?
Has anyone in the family received orthodontic treatment? If yes, who?
What would you like orthodontic treatment to accomplish?
Are you interested in
Metal braces
Ceramic (clear) braces
Invisialign
Name of your general dentist
Phone Number
Frequency of dental check-ups
Once/year
Twice/year
Date of last dental exam
Answer yes if applicable now or in the past:
Apprehensive about dental care
Yes
No
Discomfort from teeth
Yes
No
Previous orthodontic therapy
Yes
No
Teeth that are shifting
Yes
No
Frequent canker sores
Yes
No
Thumb/finger sucking as a child
Yes
No
Fluoride treatments
Yes
No
Any injuries to face, mouth, teeth
Yes
No
Speech therapy
Yes
No
Injury involving teeth
Yes
No
Injury to either jaw
Yes
No
Frequent clenching of teeth
Yes
No
Grinding of teeth
Yes
No
Wake up with sore teeth
Yes
No
Wake up with sore jaw
Yes
No
Jaw joint sounds
Yes
No
Jaw joint pain
Yes
No
Jaw tires when eating
Yes
No
Jaw catches when opening
Yes
No
Jaw locks in closed position
Yes
No
Jaw locks in open position
Yes
No
Facial pain
Yes
No
Frequent headaches
Yes
No
Neck or shoulder pain
Yes
No
Tonsils/Adenoids removed
Yes
No
Any missing permanent teeth
Yes
No
Any discomfort from gums
Yes
No
Requires premedication
Yes
No
Other:
If you checked yes to any of the above, please explain:
Does any genetically related family member have a similar facial/dental appearance?
Medical History
Patient's Physician
Approximate date of last exam
Are you currently in good physical health?
Yes
No
If no explain
Answer yes if applicable now or in the past:
Allergic to latex
Yes
No
Allergic to metals
Yes
No
Anemia/Radiation treatment
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Congenital heart defect
Yes
No
Diabetes
Yes
No
Ever been hospitalized
Yes
No
Heart attack/Stroke
Yes
No
Heart murmur
Yes
No
Hepatitis
Yes
No
Hormone therapy
Yes
No
Mouth breathing
Yes
No
Prolonged bleeding
Yes
No
Psychological counseling
Yes
No
Rheumatic fever
Yes
No
Seizures/Epilepsy
Yes
No
Taking medications
Yes
No
Tuberculosis
Yes
No
Drug allergies
Yes
No
Requires premedication
Yes
No
Other
If you checked yes to any of the above, please explain
Signature of Patient
Date
Submit
Office Locations
ORLAND PARK
15100 S. LaGrange Rd.,
Orland Park, Illinois 60462
ph. 708.349.1740