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Patient information

PATIENT INFORMATION
Patient’s Full Name__________________________________________ Date of Birth_______________ Age_______ Sex______
Address______________________________________________City/State_________________________Zip Code___________Home Phone_________________________________ SSN_________ ____________ Email_____________________________________ Names of friends or relatives who were former patients___________________________________________________________Who may we thank for referring you to our office? _____________________________________________________________ Patient’s Dentist__________________________________ Patient’s Physician_______________________________________
INSURANCE INFORMATION
Insured’s Name_________________________________ Date of Birth ___________ Insured's Social Security #_______________Insurance Company_____________________________________________ Group #_____________Local #_________________Insurance Company Address_________________________________________________________________________________Insurance Company Phone #______________________________Insured's Employer___________________________________ Insured’s Name_________________________________ Date of Birth___________ Insured's Social Security #_______________Insurance Company_____________________________________________ Group #_____________Local #_________________Insurance Company Address_________________________________________________________________________________Insurance Company Phone #______________________________Insured's Employer___________________________________ DENTAL HISTORY
Does patient receive regular dental checkups? YES NOLast dental exam___________________________________ Last dental x-rays_________________________________________Has patient received any previous orthodontic consultation or treatment?____________________________________________How often does patient brush their teeth?_______________________ Is floss used?_____________ How often?_____________Does the patient currently have, or has the patient ever had any of the fol owing? Any clicking, popping or pain of jaw, joints (TMJ) What?_______________________________________________ What are you or your Dentist most concerned about? (Purpose of visit)______________________________________________ ________________________________________________________________________________________________________ CONTINUED ON BACK --------->
ORAL HISTORY
The fol owing are some habits commonly found which may influence tooth position. List info as pertains to patient: Other habits______________________________________________________________________________________________ Has patient ever had any speech therapy?______________________________________________________________________ List any musical wind instruments played_______________________________________________________________________ HEALTH HISTORY
Has patient been under the care of a physician during the past two years? (other than routine checks) If yes, what for?___________________________________________________________________________________________Is patient currently taking medications?________________________________________________________________________Is patient al ergic to anything (drugs, food, pol en, etc.)?___________________________________________________________ Does the patient currently have, or has the patient ever had any of the fol owing?Y N Tonsils Removed Have you been diagnosed or treated for osteoporosis? Y N If yes, have you ever taken or are you now currently taking: Fosamax Didronel Boniva Actonel Reclast or a generic form of Bisphosphonates Does the patient have any special problems not listed above? ______________________________________________________ ________________________________________________________________________________________________________ EMERGENCY INFORMATION
Name of emergency contact person_____________________________________________________________________Relation____________________________________________ Phone #_____________________

Source: http://www.morganorthodontics.com/wp-content/uploads/pdf/NEW_PATIENT_INFORMATION_ADULT(VERSION2).pdf

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Andrea R. Castillo, Assistant Professor Curriculum Vitae Eastern Washington University 258 Science Building Cheney, WA 99004-2440 Phone: (509) 359-2866, Fax: (509) 359-6867, email: acastillo@mail.ewu.edu Current Position: Assistant Professor of Biology, Eastern Washington UniversityPostdoctoral fellow with Dr. Karen Ottemann, University of California, Santa Cruz, CAPostdoctoral fellow with Dr

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Assistant Professor, St. Jerome’s University Mathematics DepartmentCross-appointed, University of Waterloo Pure Mathematics DepartmentAffiliate, Perimeter Institute for Theoretical PhysicsMathematics Department,St. Jerome’s University,290 Westmount Rd N, Waterloo, Ontario, Canada N2L 3G3. geometric analysis, differential and algebraic geometry, gauge theory, mathematical physics. 1. (201

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