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New Patient Information

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New Patient Form: Adult

Name:*
Today's date:*
Address:*
Date of Birth:*
City:*
Zip Code:*
Sex:*
Cell Phone #:*
Email:*
SMS Carrier:*
Person Responsible for account:*
Do you have dental insurance?*
Dentist Name:*
Physician's Name:*
How did you learn of our office:*
Medical History:

Please give details for all questions answered "Yes".

Has the patient ever been treated for:
Headache*
- Yes
- No
Epilepsy*
- Yes
- No
Heart Problems*
- Yes
- No
Ear Aches*
- Yes
- No
Asthma*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Eye Problems*
- Yes
- No
Kidney Problems*
- Yes
- No
Bone Disorders*
- Yes
- No
Stomach Problem*
- Yes
- No
Diabetes*
- Yes
- No
Bleeding*
- Yes
- No
Anemia*
- Yes
- No
Pneumonia*
- Yes
- No
Hepatitis*
- Yes
- No
Nervous Problems*
- Yes
- No
Herpes*
- Yes
- No
AIDS*
- Yes
- No
Details:*
Is the patient in good health?*
- Yes
- No
*
Is there history of major illness?*
- Yes
- No
*
Any medications being taken now?*
- Yes
- No
*
Any allergies?*
- Yes
- No
*
Are you a smoker?*
- Yes
- No
*
Any major surgeries?*
- Yes
- No
*
Dental History:
Have there been any injuries to teeth/face?*
- Yes
- No
Any history of:
Issue with chewing?*
- Yes
- No
Tooth grinding / clenching?*
- Yes
- No
Pain in ear region?*
- Yes
- No
Limitation in jaw opening?*
- Yes
- No
Clicking of the jaw joint?*
- Yes
- No
Mouth breathing?*
- Yes
- No
Does the patient have speech problems?*
- Yes
- No
Are you aware of any missing / extra teeth?*
- Yes
- No
Has your dentist removed any teeth?*
- Yes
- No
Is there a family history of a similar bite condition?*
- Yes
- No
Have you been diagnosed with TMJ disorder*
- Yes
- No
Are you self-conscious about your teeth?*
- Yes
- No
Have you been diagnosed with periodontal disease?*
- Yes
- No
CAPTCHA

ESTHER FELDMAN DMD MSC

11600 WILSHIRE BLVD SUITE 226. LOS ANGELES CA 90025

DrFeldmanOrtho.com . (424)299-4270 . service@drfeldmanortho.com

New Patient Form: Child

Date:
Name:*
Date of Birth:*
Sex:*
Address:*
City:*
Zip Code:
Home Phone #:*
School:*
Email Address:*
Person Responsible for Account:*
Do You Have Dental Insurance?*
Physician's Name:*
Dentist's Name:*
How Do Learn Of Our Office?*
MEDICAL HISTORY

Please give details for all questions answered "YES"

Has the patient ever been treated for:
Headaches*
- Yes
- No
Epilepsy*
- Yes
- No
Heart Problem*
- Yes
- No
Ear Aches*
- Yes
- No
Asthma*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Eye Problems*
- Yes
- No
Kidney Problems*
- Yes
- No
Bone Disorders*
- Yes
- No
Stomach Problems*
- Yes
- No
Diabetes*
- Yes
- No
Bleeding*
- Yes
- No
Anemia*
- Yes
- No
Pneumonia*
- Yes
- No
Hepatitis*
- Yes
- No
Nervous Problems*
- Yes
- No
Herpes*
- Yes
- No
AIDS*
- Yes
- No
Detail:*
Is the patient good in health?*
- Yes
- No
Is there history of major illness?*
- Yes
- No
Any medications being taken now?*
- Yes
- No
Any allergies?*
- Yes
- No
Girls: has menstruation begun?*
- Yes
- No
Boys: has voice changed?*
- Yes
- No
Dental History
Have there been any injuries to teeth / face?*
- Yes
- No
Any History of:
Thumb sucking / pacifier habit?*
- Yes
- No
Tooth grinding / clenching?*
- Yes
- No
Pain in ear region?*
- Yes
- No
Limitation in jaw joint?*
- Yes
- No
Clicking of the jaw joint?*
- Yes
- No
Mouth breathing?*
- Yes
- No
Does the patient have speech problems?*
- Yes
- No
Are you aware of any missing / extra teeth?*
- Yes
- No
Has your dentist removed any teeth?*
- Yes
- No
Is there family history of a similar bite condition?*
- Yes
- No
Has another family member had Orthodontic treatment?*
- Yes
- No
Is the patient self-conscious of his / her teeth?*
- Yes
- No
Is the patient motivated toward Orthodontic Treatment?*
- Yes
- No
CAPTCHA

ESTHER FELDMAN DMD MSC

11600 WILSHIRE BLVD SUITE 226. LOS ANGELES CA 90025

DrFeldmanOrtho.com . (424)299-4270 . service@drfeldmanortho.com

ESTHER FELDMAN DMD MSC

11600 WILSHIRE BLVD SUITE 226. LOS ANGELES CA 90025

DrFeldmanOrtho.com . (424)299-4270 . service@drfeldmanortho.com

Our goal is to collaborate with you to craft the healthy smile you deserve

11600 WILSHIRE BLVD SUITE 226
LOS ANGELES CA 90025
Phone: (424)299-4270
service@drfeldmanortho.com

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