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ADULTS MEDICAL HISTORY

READ THIS INSTRUCTIONS BEFORE ANSWERING: In order to agree and sign this questionarie, it's important to answer all the questions. If any of them is empty it won't allow you to finish. In case you don't know what to reply, or if it's not your case you can write, for example: "no", "IDK" " N/A", etc.

ADULTS MEDICAL HISTORY

Name of the patient:

Birthdate of the patient:

Occupation:

Adress:

Email adress:

ORTHODONTIC HISTORY

What is your primary concern in seeking orthodontic treatment?

How did you know about our office? Please write the name of the person/dr. who recommended you:

Did you have orthodontic treatment before?

Yes, fixed

Yes, removable

When?

Anybody in your family wear braces? Who?

Was their problem similar to yours?

Yes

I don't know

MEDICAL HISTORY

Are you in good health?

Yes

Check any of the following for which you have been treated:

Diabetes

Pneumonia

Asthma

Tuberculosis

Heart disease

Rheumatic fever

Bone disorders

Anemia

Prolonged bleeding

Kidney disease

Liver disease

Hepatitis

Endocrine problems

Fainting or dizziness

Epilepsy

Nervous disorders

Blood transfussions

Slow digestion

Allergies or sensitivity

None

Others

If you've checked on allergies, please mention which:

In case you've checked any of the above, please explain:

List any drugs or medications currently being taken:

List any surgeries that you have undergone and their dates:

In case you're a woman: Are you possibly pregnat or in a lactation period currently?

Yes

IDK

Do you have tendency to:

Colds

Sore throat

Ear infections

Sinusitis

None

Are you a mouthbreaker?

Yes

I don't know

Do you snore?

Yes

I don't know

Do you smoke?

Yes

I've never smoked

Nº if cigarrettes per day:

When did you stop smoking?

Approximate date of the last dental check up:

Name of your general dentist:

How often do you brush your teeth per day?

Do your gums bleed while brushing?

Yes

Your general dentist is DR.

Have you been treated from periodontal disease?

Yes

When? By DR.

Have you ever had an occlusal adjustment?

Yes

When? By DR.

Do you have any habits like:

Biting lips

Biting nails

Biting pens

Speech problems

Frequently chew gum

Sucking a thumb or other fingers

Used the pacifier and/or milk bottle beyond 3 years of age

None

For how long have you had this habit?

Do you practise any sport? If so, what?

Have you ever lost or chipped any teeth?

Yes

Did oyu have any severe injure to the face, mouth or teeth?

Yes

I don't remember

How did it occur and when?

PLEASE, ANSWER YES OR NO TO THE FOLLOWING QUESTIONS

Do your teeth or jaws ever feel uncomfortable when you awake in the moring?
Yes

No
Are you aware of clenching your teeth during the day?
Yes

No
Have you ever been told that you grind your teeth?
Yes

No
Do you have any pain around your eyes, ears or any other area of your face?
Do you have 'tension' headaches?
Yes

No
Do you often suffer for stiffness, pain or spasms on the neck?
Yes

No
Do your jaw muscles easily get tired?
Yes

No
Have you been diagnosed with fibromyalgia or chronic fatigue?
Have there been any injuries to face, neck, mouth or teeth? (car accident, whiplash, etc)
Yes

No

If so, please explain:
Do you have a scar on your chin?
Yes

No
Did you ever have pain in your tm joint?
Yes

No
Did you have any treatment due to facial muscular spasm o tm joint problems?
Yes

No
Are you experiencing chronic ringing in your ears?
Yes

No
Are you aware of your jaws clicking or popping?
Yes

No
Do you have sleep disorders?
Yes

No
Do you take aspirin or any other pain killer frequently?
Yes

No
Are you currently taking any tranquilizing, hypnotic, anti depressive drug or muscle relaxant?
Yes

No
Do you drink more than one glass of alcohol a day?
Yes

No
Are you having difficulties chewing your food?
Yes

No
Have you experienced locked jaw?
Yes

No
Have you ever had the feeling when you wake up that you couldn't open your mouth?
Yes

No
Are you comfortable with the way you chew?
Yes

No
Are you currently feeling pain on your lower jaw or TMJ?
Yes

No
Have you ever dislocated your jaw after opening it too much?
Yes

No
Do you recently had any change in your lifestyle? (marital status, birth, bereavement, job change, or other stressful situation)
Yes

No
Do you have problems in any other joints?
Yes

No
Do you think that stress is related to your problems?
Yes

No
Are you currently pregnant or do you think you might be?
Yes

No

DOCTOR'S COMMENTS: (Just leave it blank if you're filling this questionarie at our clinic. If not, you can use some of the abbreviation mentioned before, in order to agree and sign the document).

THE OWNER AUTHORIZES THE PROCESSING OF THEIR DATA WITH THE PURPOSE OF PROVIDING SERVICES
ORTHODONTICS AND THE NECESSARY STEPS TO COMPLETE THE SERVICE, SIMILARLY AUTHORIZES THE SENDING OF INFORMATION SERVICES AND REVISIONS THAT ARE COMMENSURATE WITH THEIR TREATMENT. THIS CONSENT MAY BE REVOKED AT ANY TIME. YOU CAN EXERCISE THEIR RIGHTS UNDER THE TERMS OF THE ORGANIC LAW ON PROTECTION OF PERSONAL DATA 15 1999 DECEMBER 13, BY WRITING TO SOLUCIONES ODONTOLOGICAS KAIZEN S.L.P.U. CALLE PINSAPO, Nº 8 -1ºB, 29601 MARBELLA - MALAGA.

DATA CONSENT

as patient of Kaizen Ortodoncia, with DNI/NIE/PASPORT :

Checking the following boxes, I do or do not authorize to SOLUCIONES ODONTOLÓGICAS KAIZEN S.L.P.U., to send me by any media communications (phone/email/sms/ message apps) newsletter, Christmas Greetings, commercial information about new products, services, promotions and discounts, etc.:

Yes

Likewise, checking the following boxes, I expressly do or do not AUTHORIZE to SOLUCIONES ODONTOLÓGICAS KAIZEN S.L.P.U. that all my personal data related with my health treatment, as pictures taken at the office, can be

Exposed on our website or social media as promotion or marketing, exposed in seminaries, courses or cientific publications as instruction

Yes

No
Shared with other professionals as clinical research (for example, your general dentist)
Yes

No

De conformidad con la Ley Orgánica 15/1999, de 13 de diciembre, de Protección de Datos de Carácter Personal, SOLUCIONES ODONTOLÓGICAS KAIZEN SLPU. le informa que sus datos personales serán tratados y quedarán incorporados en los ficheros de su propiedad, con la finalidad de prestarle los servicios sanitarios solicitados y la gestión administrativa y de facturación derivada de los mismos. Las respuestas a las cuestiones planteadas tienen carácter obligatorio, en caso de no suministrar los datos requeridos, no será posible la prestación del servicio solicitado. El titular de los datos se compromete a comunicar a SOLUCIONES ODONTOLÓGICAS KAIZEN SLPU cualquier modificación que se produzca en los datos aportados de forma que se mantengan siempre exactos y puestos al día. En cualquier caso, sus datos serán considerados confidenciales y solamente serán utilizados con fines internos. A su vez le informamos de que las imágenes obtenidas con las cámaras de videovigilancia serán únicamente destinadas a la finalidad de seguridad y vigilancia de las instalaciones.
Asimismo, le informamos que usted podrá ejercitar sus derechos de acceso, rectificación, cancelación y oposición mediante escrito, acompañado de copia de documento oficial que le identifique, dirigido a SOLUCIONES ODONTOLÓGICAS KAIZEN SLPU., C/ Pinsapo n.º 8, 1º B, MARBELLA-29601 MALAGA.

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Timestamp

Audit

04/10/2021 16:14 CEST

ADULTS MEDICAL HISTORY Uploaded by Lourdes Bueno - recepcion@clinicakaizen.com IP 81.37.14.240