True Alignment Ortho
07 823 5297
info@truealignment.co.nz
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Reason for visit
*
Breathing Issues
Snoring
I'd like to enquire about Invisalign Clear Aligners
Reversing previous extraction orthodontic treatment
Re-treatment due to relapse
Buck or protruding teeth
Crowded teeth
Undershot jaw
Overshot jaw
Crossbite
Uneven bite
Gaps
Irregularly shaped teeth
Missing tooth/teeth
An orthodontic second opinion
Overly small mouth
Prominent lower jaw
Receded lower jaw
Facial pain
Gum disease or recession
Head pain
Irregular facial proportions
Jaw dysfunction or clicking
Jaw pain
Mismatched bite
Neck pain - frequent
Referred by dentist/dental nurse
No particular reason other than to check for problems
Other (please state below)
What don't you like about your smile?
*
Medication currently being taken
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Antibiotics
Anticoagulants
Cortisone
Diet pills
Heart medication
Insulin
Muscle relaxants
Nerve pills
Pain medication
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Tranquilisers
None reported
Other (please list below)
Other medication
Medical history
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Adenoids have been removed
Tonsils have been removed
Asthma
Autoimmune
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Cancer
Endocrine disorders
Facial pain
Headaches
Hearing impairment
Injury to face
Injury to head
Injury to mouth
Injury to teeth
Other (please list below)
Haemophillia
Hepatitis
Jaw pain
Kidney problems
Muscle aches
Neck pain
Prior orthodontic treatment
Rheumatic fever
Ringing of the ears
Shortness of breath
High blood pressure
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Snoring
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Tuberculosis
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Heart murmur
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Allergy
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Plastic allergy
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Other allergy
Habits
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Grinding / Clenching of teeth
Lip biting
Prior thumb or finger
Current thumb or finger
Nail biting
Prior mouth breathing
Current mouth breathing
No reported habits
Other (please list below)
Other allergy (copy)
Other notes
Do you affirm that the information given in this questionnaire is true and accurate to the best of your knowledge? I authorise staff, after consultation with myself, to perform such dental services as may be necessary and authorise the release of written documents to any referring or treating dentist, physician, medical facility or insurance company or for legal documentation.
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I accept full responsibility for all charges for treatment to the patient understanding I will be informed beforehand, of all costs.
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