Kaizen Ortodoncia

CHILDREN MEDICAL HISTORY


READ THIS INSTRUCTIONS BEFORE: 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

Name of the patient:  

Birthdate of the patient:  

FAMILY INFORMATION

Father's name:    Occupation:  

Mother's name:     Occupation:  

Email of the father/mother:  

Adress:  

School:  

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/doctor who recomended you:  

Did the patient had orthodontic treatment before?

 

Did anybody in the patient's family wear braces? Who?  

Was their problem similiar to the patient's?

 

How many siblings does the patient have? Note names and ages, please  

MEDICAL HISTORY

Is the patient in good health?

   

Please, check any of the following for which the patient has been treated:

 

If the patient has any allergies, please mention which ones:  

If you have checked any of the above, please explain:  

List any drugs or medications currently being taken:  

List any surgeries that the patient have undergone and their dates:  

Does the patient have tendency to:

 

Is he/she a mouthbreather?

 

Does he/she snores?

 

Have he/she reached puberty?

 

If so, please write the approximate date:  

Name of your family dentist:  

Approximate date of the last dental check up:  

How often does the patient brush her/his teeth per day?

 

Does the patient's gum bleed while brushing?

 

Patient's general dentist is:  

Does the patient have any habits like?

 

For how long have the patient has had this habit?  

At what age did the patient stop using pacifier and milk bottle?  

Does the patient practise any sport? If so, what?  

Does the patient has any fractured teeth?

   If so, please explain how and when:  

PLEASE ANSWER YES OR NO TO THE FOLLOWING QUESTIONS. 

  1. Does the patient clench her/his teeth during the day?
     
  2. Does the patient clench or grind her/his teeth while sleeping?
     
  3. Does the patient have any pain around his/her eyes, ears or any other area of the face?  
  4. Does the patient suffer from frequent headaches?
     
  5. Does the patient suffer for stiffness, pain or spasm on the neck?
     
  6. Does the patient have any rheumatic problems? (arthritis, theumatic fever, etc...)
     
  7. Has the patient been diagnosed with hiperlasticity of the ligaments?
     
  8. Has the patient suffered any trauma on his/her face or jaws?
     
  9. Does the patient have a scar on the chin?
     
  10. Does the patient suffer from ear problems such as changes in audition or hearing beeping sounds?  
  11. Does the patient ever heared a click or pop on his/her jaw joints?
     
  12. Does the patient have sleep disorders?
     
  13. Do you take aspirin or any other pain killer frequently?
     
  14. Does the patient have difficulties chewing, takes a long time to eat or make balls out of his food in his mouth?  
  15. Has the patient ever had problems to close his/her mouth?
     
  16. Has the patient had upon waking up, the feeling that he/she could not close the mouth?
     
  17.  Does the patient have problems in opening wide the mouth?
     

 

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 (or     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.:

 

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 
     
  • Shared with other professionals as clinical research (for example, your family dentist)
     

 

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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Document name: CHILDREN MEDICAL HISTORY
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29/09/2021 12:09 CESTCHILDREN MEDICAL HISTORY Uploaded by Lourdes Bueno - recepcion@clinicakaizen.com IP 81.37.14.240
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