Patient Details

Patient First Name *

Patient Last Name *

Address

Street Address

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
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Tokelau
Tonga
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Turkey
Turkmenistan
Turks and Caicos Islands
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Uganda
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Ukraine
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United States Minor Outlying Islands
Uruguay
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Virgin Islands, U.S.
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Western Sahara
Yemen
Zambia
Zimbabwe
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Zip code

Home Phone *

Cell Number *

Work Phone

Date of birth

Social Security# *

Email *

Marital Status

Single
Married
Widowed
Separated
Divorced
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Employer

Occupation

No. of years employed

Preferred Location *

Redmond
Seattle
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Whom may we thank for referring you to our office

Dental Insurance Information

Insurance Company

Insurance Phone

Subscriber Name

Subscriber Birthdate

Member ID

Group Number

Do you have dual coverage? *

Yes

No

If yes, please fill the information:

Emergency Information

Emergency Contact Full Name *

Emergency Contact Phone *

Relationship to Patient *

Medical History

Physician *

Date of Last Visit

Physician Address

Physician Phone

Are you taking any medication? *

Yes

No

Please mention

Are you allergic to any medication? *

Yes

No

Please mention allergic to any medication

Do you have a history of a major illness? *

Yes

No

Please mention history of a major illness

Have you had any operations? *

Yes

No

Please mention any operations

Have you ever been involved in a serious accident? *

Yes

No

Please mention involved in a serious accident

Have you ever smoked or chewed tobacco? *

Yes

No

Have seen a physician in the last 12 months? *

Yes

No

Why you have seen a physician in the last 12 months?

Female Patients only

Are you pregnant?

Yes

No

Has menstruation started?

Yes

No

Are you taking Birth Control?

Yes

No

Patients up to 12 years of age only

Is Your child often irritated or angry during the day?

Yes

No

Is your child’s weight above the 90% for their age group?

Yes

No

Does your child loudly snore?

Yes

No

Does your child sometimes have labored breathing at night?

Yes

No

Have you ever noticed your child stop breathing at night?

Yes

No

Does your child have enlarged tonsils and/or adenoids?

Yes

No

Does your child have problems with concentration?

Yes

No

Does your child often yawn, or is tired or sleepy during the day?

Yes

No

Check any of the medical conditions below that you have had or currently have.

Abnormal Bleeding

Diabetes Hepatitis

Pneumonia

Dizziness

Arthritis

High Blood Pressure

Asthma or Hay fever

HIV / Aids

Bone Disorders

Kidney problems

Congenital Heart Defect

Nervous Disorders

Hemophilia

Liver problems

Anemia

Herpes

Epilepsy

Radiation/Chemotherapy

Gastrointestinal Disorders

Rheumatic Fever

Heart Problems

Tuberculosis

Heart Murmur

Tumor or Cancer

None

Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

General Dentist

General Dentist Date of Last Visit

What concerns you most about your teeth?

Are you presently in any dental pain?

Yes

No

Have you ever experienced any unfavorable reaction to dentistry?

Yes

No

Have your wisdom teeth been removed?

Yes

No

Have you ever lost or chipped any teeth?

Yes

No

Have there been any injuries to face, mouth, or teeth?

Yes

No

Is any part of your mouth sensitive to temperature?

Yes

No

Where part of your mouth sensitive to temperature:

Is any part of your mouth sensitive to pressure?

Yes

No

Where (part of mouth sensitive to pressure?)

Do your gums bleed when you brush?

Yes

No

Do you have any type of thumb or tongue habit?

Yes

No

Are you a mouth breather?

Yes

No

Have you ever seen an orthodontist?

Yes

No

If yes, who and when? (you ever seen an orthodontist)

What is your attitude toward receiving orthodontic treatment?

Yes

No

Has anyone in your family received orthodontic treatment?

Yes

No

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

Yes

No

Are you aware of your jaw clicking or popping?

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 “tension” headaches?

Yes

No

Have you ever experienced chronic ringing in your ears?

Yes

No

Are you aware that some appointments will be during work hours?

Yes

No

I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Sepi Torkan to perform a complete orthodontic evaluation

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