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Patient's Last name _________________________ First name ________________________________ Middle initial ___ Prefers To Be Called ____________________ Hobbies, activities ______________________________________________ Birth date _____________________ Sex: Male School ______________________________ Grade ___________ E-mail address(es) _____________________________ Home address _____________________________________ City, State, Zip code __________________________________ Custodial parent(s) name (s) ________________________________________________________________________________ Patient lives with (check all that apply) other ________________________________________________________________ Father's full name __________________________________________ Title Occupation ____________________________________ Email address _________________________________________ Address (if different) ______________________________________________________________________________________ Home Phone (if different): ( ) - Cell phone ( ) - Work phone ( ) - Mother's full name _______________________________________ Title Occupation ____________________________________ Email address _________________________________________ Address (if different) _____________________________________________________________________________________ Home Phone (if different): ( ) - Cell phone ( ) - Work phone ( ) - Patient’s Dentist _______________________________ Address, City, State ________________________________________ Last seen ___________________ Reason ______________________________________ Next appointment ____________ Other dentists/dental specialists now being seen: Name _____________________________ City, State ________________ Reason _________________________________________________________________________________________________ What concerns you about your child’s teeth? ___________________________________________________________________ What concerns your child about his/her teeth? _________________________________________________________________ How does your child feel about orthodontic treatment? __________________________________________________________ American Association of Orthodontists 2013 Who suggested that your child might need orthodontic treatment? ________________________________________________ Why did you select our office? _______________________________________________________________________________ Describe any previous orthodontic treatment or consultations. ___________________________________________________ Does your child play a musical instrument? ____________________________________________________________________ Brother/sister name age had orthodontic treatment? Brother/sister name age had orthodontic treatment? Brother/sister name age had orthodontic treatment? Brother/sister name age had orthodontic treatment? Have any other family members been treated in this office? Please name them. ____________________________________ Who is financially responsible for this account? ________________________________________________________________ Address (if different from page 1) ______________________________City, State, Zip __________________________________ Home phone ( ) - Cell phone ( ) - E-mail address(es) ___________________________ Social Security # - - Employer: ________________________________________________ Who will be responsible for bringing the patient to orthodontic appointments? Primary policy holder’s full name ________________________________________________ Birth date ___________________ Social Security # - - Relationship to patient _________________________________________________ Address and phone (if not listed above) ________________________________________________________________________ Employer _________________________________ Address _______________________________________________________ Insurance company ____________________________________ Group # ________________ ID # _______________________ Does this policy have orthodontic benefits? Secondary policy holder’s full name ______________________________________________ Birth date ___________________ Social Security # - - Relationship to patient _________________________________________________ Address and phone (if not listed above) ________________________________________________________________________ Employer _________________________________ Address ________________________________________________________ Insurance company _____________________________________ Group # ________________ ID # _______________________ Does this policy have orthodontic benefits? Policy holder’s full name _____________________________________________________________________________________ Insurance company _________________________________________________________________________________________ Patient’s Physician __________________________ City, State _____________________________________________________ Last seen ____________ Reason ________________________________________________ Next appointment ____________ Most recent physical exam ____________________________________________________________________________________ American Association of Orthodontists 2013 Other physicians/health care providers being seen now: Name ________________________________________ City, State __________________________________________________ Reason ____________________________________________________________________________________________________ Name ________________________________________ City, State __________________________________________________ Reason ____________________________________________________________________________________________________ Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u). Has your child had allergies or reactions to any of the following? dk/u Local anesthetics (novocaine, lidocaine, xylocaine) dk/u Birth defects or hereditary problems? dk/u Cancer, tumor, radiation treatment or chemotherapy? dk/u Gonorrhea, syphilis, herpes, sexually transmitted dk/u Hepatitis, jaundice or other liver problems? Now or in the past, has the patient had: dk/u Polio, mononucleosis, tuberculosis, pneumonia? dk/u Erupting teeth very early or very late? dk/u Seizures, fainting spells, neurologic problem? dk/u Primary (baby) teeth removed that were not loose? dk/u Mental health disturbance or depression? dk/u Permanent or extra (supernumerary) teeth removed? dk/u History of eating disorder (anorexia, bulimia)? dk/u Supernumerary (extra) or congenitally missing teeth? dk/u Chipped or injured primary or permanent teeth? dk/u Excessive bleeding or bruising tendency, anemia? dk/u Chest pain, shortness of breath, tire easily, swollen dk/u Heart defects, heart murmur, rheumatic heart disease? dk/u Any teeth treated with root canals or pulpotomies? dk/u Frequent canker sores or cold sores? dk/u Angina, arteriosclerosis, stroke or heart attack? dk/u History of speech problems or speech therapy? dk/u Skin disorder (other than common acne)? dk/u Does your child eat a well-balanced diet? dk/u Mouth breathing habit or snoring at night? dk/u Vision, hearing, or speech problems? dk/u Frequent ear infections, colds, throat infections? dk/u Frequent oral habits (sucking finger, chewing pen, etc.)? dk/u Teeth causing irritation to lip, cheek or gums? dk/u Does your child frequently breathe through his/her dk/u Has your child ever taken intravenous bisphosphonates dk/u Soreness in jaw muscles or face muscles? such as Zometa (zolendromic acid), Aredia dk/u Has your child been treated for “TMJ” or “TMD” (pamidronate) or Didronel (etidronate) for bone disorders dk/u Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva dk/u Any serious trouble associated with previous dental (ibandronate), Skelid (tiludronate) or Didronel dk/u Has your child ever been diagnosed with gum disease or American Association of Orthodontists 2013 Do you think that any of your child’s activities affect his/her face, teeth or jaws? How? __________________________________ List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes. Medication _______________________________ Taken for ___________________________________________________________ Medication _______________________________ Taken for ___________________________________________________________ Medication _______________________________ Taken for ___________________________________________________________ Do you take antibiotic pre-medication before any dental procedures? Does the patient currently have (or ever had) a substance abuse problem? _____________________________________________ Does your child chew or smoke tobacco? _________________________________________________________________________ Have you noticed any unusual changes in your child’s face or jaws? ___________________________________________________ Any other physical problems? ___________________________________________________________________________________ FAMILY MEDICAL HISTORY Have the parents or siblings ever had any of the following health problems? If so, please explain. Bleeding disorders ____________________________________________________________________________________________ Diabetes ____________________________________________________________________________________________________ Arthritis _____________________________________________________________________________________________________ Severe allergies ______________________________________________________________________________________________ Unusual dental problems ______________________________________________________________________________________ Jaw size imbalance ___________________________________________________________________________________________ Other family medical conditions? _______________________________________________________________________________ How often does your child brush? _______________________________________________________________________________ Floss? ______________________________________________________________________________________________________ RELEASE AND WAIVER I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company. Parent/Guardian Signature ____________________________________________________________ Date____________________________ I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.
Parent/Guardian Signature ____________________________________________________________ Date____________________________ MEDICAL HISTORY UPDATES Changes Parent/Guardian Signature ____________________________________________________ Date____________________________ Dental Staff Signature ________________________________________________________ Date____________________________ Changes Parent/Guardian Signature ____________________________________________________ Date____________________________ Dental Staff Signature ________________________________________________________ Date____________________________ Changes Parent/Guardian Signature ____________________________________________________ Date____________________________ American Association of Orthodontists 2013 Dental Staff Signature ________________________________________________________ Date____________________________ American Association of Orthodontists 2012 2013

Source: http://www.koko-ortho.com/Child%20Medical%20History_11Sep2013.pdf

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RULES AND REGULATIONS OF THE MEDICAL-DENTAL STAFF Patients who are known to be suffering from drug abuse, alcoholism, and mental illness shall not be admitted unless proper safety precautions can be taken to safeguard the patient, other patients, and employees. Only practitioners granted Staff membership and clinical privileges may admit patients to this health center except as provided i

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Maintaining remission of ulcerative colitis with the probioticEscherichia coli Nissle 1917 is as effective as with standardmesalazineW Kruis, P Fricˇ, J Pokrotnieks, M Luka´sˇ, B Fixa, M Kasˇcˇa´k, M A Kamm, J Weismueller, C Beglinger,M Stolte, C Wolff, J Schulze. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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