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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
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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
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
SCHEDULE A COMPLIMENTARY
CONSULTATION »
Confidential Youth Patient Health History Form
Primary Parent’s Information
Date
Name of Primary Parent
Last
First
Middle
Address (Street, City, State, Zip)
How long at this address
Previous Address (if less than 3 years at current):
SSN#
Birth Date
Relationship to Patient
Email address we can use for appointment reminders
Employer
Occupation
# of years employed
Parent’s/Spouse Name
Last
First
Middle
Relationship to Patient
Birth Date
Employer
Occupation
# of years employed
Patient Information
Patient Name
Last
First
Middle
Birth date
Age
Gender
Male
Female
Other
SSN#
If patient is a minor, give parent's or guardian's name(s)
If the patient has siblings, please give the sibling's name(s)
Home phone
Whom may we thank for referring you to our office?
Insurance Information
Policy Holder
Last
First
Middle
SSN#
Birth Date
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
Emergency Contact Information
Name of nearest relative not living with you:
Address of Relative
Phone
Relationship
Dental and Medical History
What are the main concerns that you would like orthodontics to accomplish?
Name of your child's general dentist
Phone
Answer yes if applicable now or in the past:
Any past orthodontic evaluations, consultations or treatment
Yes
No
If yes, when?
Any injuries to face, mouth, teeth
Yes
No
Plays a musical instrument
Yes
No
If yes, what instrument?
Tonsils/Adenoids removed
Yes
No
Been informed of any missing or extra permanent teeth
Yes
No
Jaw joint pain or tenderness
Yes
No
Floss his/her teeth daily
Yes
No
Is your child currently under the care of a physician
Yes
No
If yes..
Physician name
Phone
Date of last visit
Has your child begun puberty
Yes
No
If patient is a girl, has menstruation begun
Yes
No
Please describe your child's current physical health
Good
Fair
Poor
Please list all drugs/medications that your child is currently taking
Please list all drugs/things that your child is allergic to
Other allergies
Latex
Yes
No
Metals/Nickel
Yes
No
Plastics
Yes
No
Has your child had any of the following medical conditions?
Abnormal bleeding
Yes
No
ADD / ADHD
Yes
No
Any hospital stays or surgical operations
Yes
No
Heart murmurs
Yes
No
Artificial joints, bones, or valves
Yes
No
Hepatitis
Yes
No
HIV / AIDS
Yes
No
Kidney or liver problems
Yes
No
Rheumatic / Scarlet fever
Yes
No
Convulsions / Epilepsy
Yes
No
Diabetes
Yes
No
Handicaps / Disabilities
Yes
No
Hemophilia
Yes
No
Asthma
Yes
No
Cancer
Yes
No
Congenital Heart Defect
Yes
No
Lupus
Yes
No
Tuberculosis
Yes
No
Has your child ever experienced any of the following?
Clenching / Grinding teeth
Yes
No
Nursing bottle habits
Yes
No
Mouth Breather
Yes
No
Nail Biting
Yes
No
Speech Problems
Yes
No
Lip Sucking / Biting
Yes
No
Thumb / Finger Sucking
Yes
No
Tongue Thrust
Yes
No
Other:
If you checked yes to any of the above, please explain
Signature of Parent/Guardian
Date
Submit
Office Locations
ORLAND PARK
15100 S. LaGrange Rd.,
Orland Park, Illinois 60462
ph. 708.349.1740