Woodland, CA Family Orthodontist
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Hours: M-F 8:00a - 5:00p
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In-Office Appointments
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Why Us?
Why Choose Portalupi
Meet Dr. Portalupi
Meet Your Team
Invisalign®
How Does Invisalign® Work?
Invisalign® for Adults
Invisalign® for Teens
Braces
Different Types of Braces
Braces for Adults
Braces for Teens
Blog
New Patients
What to Expect
Financing & Insurance
Patient Forms
Patient Registration Form
Health Questionnaire
Patient Smile Evaluation
Epworth Sleepiness Scale
HIPAA Consent Form
iCat Informed Consent
Contact
Contact Us
In-Office Appointments
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Health Questionnaire
Home
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Health Questionnaire
Patient Forms
New Patient Health Questionnaire
Step 1 of 4
25%
Part 1: Patient Information
Patient's Full Name
*
Date of Birth (mm/dd/yyyy)
*
Age
*
Gender
*
Male
Female
Part 2: Subjective Complaints and Concernts
Does the patient suffer from any of the following:
Facial Pain
*
Mild
Moderate
Severe
No
Gum Disease / Recession
*
Mild
Moderate
Severe
No
Gum Problems
*
Mild
Moderate
Severe
No
Headaches
*
Mild
Moderate
Severe
No
Jaw Disfunction
*
Mild
Moderate
Severe
No
Jaw Joint Sounds
*
Mild
Moderate
Severe
No
Jaw Pain
*
Mild
Moderate
Severe
No
Neck Pain
*
Mild
Moderate
Severe
No
Ringing or 'Stuffy' Ears
*
Mild
Moderate
Severe
No
What are the patient's or parents' main concerns regarding the jaw and teeth?
*
Bad Bite
“Buck” Teeth / Overjet
Crowding of Upper Teeth
Crowding of Lower Teeth
Crowding of Upper and Lower Teeth
Crossbite
Dentist Recommended Seeing an Orthodontist
Grinding Teeth
Gummy Smile
Impacted Tooth / Teeth
Improper Tooth Position
Irregular Facial Proportions
Irregular Shaped Tooth / Teeth
Missing Tooth / Teeth
Mouth Too Small
Open Bite
Overbite
Prominent Lower Jaw (too “strong”)
Protrusion of Teeth
Recessive Lower Jaw (too “weak”)
Rotations
Small Teeth
Spaces
Thumb / Finger Habit
Underbite
None
Other
If 'Other' please explain
Family members with similar problems:
Father
Mother
Brother
Sister
None
Other
If 'Other' please explain
Part 3: Medical and Dental History
How would you rate the patient's overall health?
Physical Health
*
Good
Fair
Poor
Mental Health
*
Good
Fair
Poor
Stress Level
*
Good
Fair
Poor
Has the patient reached puberty?
*
Yes
No
Has the patient ever had any of the following conditions?
Allergies
*
Yes
No
AIDS / ARC / HIV
*
Yes
No
Arteriosclerosis
*
Yes
No
Asthma
*
Yes
No
Autoimmune Disorder
*
Yes
No
Blood Disease
*
Yes
No
Bone Disorder
*
Yes
No
Cancer
*
Yes
No
Diabetes
*
Yes
No
Dizziness
*
Yes
No
Emotional Problems
*
Yes
No
Endocrine Problems
*
Yes
No
Epilepsy
*
Yes
No
Female Problems
*
Yes
No
Frequent Headaches
*
Yes
No
Glaucoma
*
Yes
No
Hay Fever
*
Yes
No
Hearing Disorders
*
Yes
No
Heart Disease / Surgery
*
Yes
No
Hepatitis
*
Yes
No
Herpes / Fever Blisters
*
Yes
No
High Blood Pressure
*
Yes
No
Low Blood Pressure
*
Yes
No
Hospitalized for Any Reason
*
Yes
No
Kidney Disease
*
Yes
No
Lupus
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Pacemaker
*
Yes
No
Psychiatric Problems
*
Yes
No
Radiation Treatment
*
Yes
No
Rheumatic Fever
*
Yes
No
Ringing of Ears
*
Yes
No
Seizures
*
Yes
No
Sinus Problems
*
Yes
No
Sleep Disturbance
*
Yes
No
Stroke
*
Yes
No
Thyroid Problems
*
Yes
No
Trauma (to face, teeth, jaws, or head)
*
Yes
No
Tuberculosis (TB)
*
Yes
No
Ulcers
*
Yes
No
Venereal Disease
*
Yes
No
Is the patient currently taking any of the following medications?
*
Antibiotics
Birth Control Pills
Diet Pills (Diuretics)
Heart Pills (Digitalis, etc.)
Insulin
Muscle Relaxants (Valium, etc.)
Pain Pills (Demerol, Codeine, etc.)
Sleeping Pills
Tranquilizers (Elavil, Valium, etc.)
Vitamins
Other
None
If 'Other' please explain
Is the patient allergic to any of the following foods or medications?
*
Antibiotics
Aspirin
Codeine
Dairy Products
Dental Anesthetics
Erythromycin
Food Dyes
Jewelry / Metals
Latex
Pain Pills
Wheat
Other
None
Which antibiotic(s)?
Which pain medication(s)?
If 'Other' please explain
Has the patient ever had a history of the following?
Colds
*
Occasionally
Frequently
No
Difficulty Chewing
*
Occasionally
Frequently
No
Difficulty Swallowing
*
Occasionally
Frequently
No
Finger Sucking
*
Occasionally
Frequently
No
Grinding Teeth
*
Occasionally
Frequently
No
Headaches
*
Occasionally
Frequently
No
Lip Biting
*
Occasionally
Frequently
No
Mouth Breathing
*
Occasionally
Frequently
No
Pain in Jaw Joint
*
Occasionally
Frequently
No
Smoking
*
Occasionally
Frequently
No
Snoring
*
Occasionally
Frequently
No
Sore Teeth
*
Occasionally
Frequently
No
Sore Throat
*
Occasionally
Frequently
No
Speech Problems
*
Occasionally
Frequently
No
Thumb Sucking
*
Occasionally
Frequently
No
Tongue Thrusting
*
Occasionally
Frequently
No
Tonsillitis
*
Occasionally
Frequently
No
Other
*
Occasionally
Frequently
No
If 'Other' please explain
Patient's or Parents' Attitude Towards Teeth Care and Orthodontic Treatment
How often does the patient have regular dental checkups?
*
Twice a year
Once a year
Only if necessary
Never
Patient’s interest in orthodontic treatment:
*
Eager for treatment
Willing if necessary
Dreading but agrees
Unwilling
Orthodontic consultation was prompted by:
*
Patient
Dentist
Spouse
Mother
Father
Brother
Sister
Other relative
Friend
Other
What is their name?
Has the patient ever had any unusual dental experiences?
*
Yes
No
Please explain
Are there any medical, dental, surgical, or psychological problems not covered above?
*
Yes
No
Please explain
Has the patient ever had a previous orthodontic consultation/treatment?
*
Yes
No
Doctor's name and city:
Please list any other heath care professionals currently or previously seen by the patient:
Doctor's Name
Reason(s) for treatment
Doctor's Name
Reason(s) for treatment
Doctor's Name
Reason(s) for treatment
Why are you seeking this consultation?
*
Select All
To improve dental appearance
To improve facial appearance
To improve general appearance
To improve longevity of teeth
To improve self-esteem
To reduce facial pain
To reduce headaches/neckaches
Other
If 'Other' please explain
Please tell us about any other concerns or orthodontic goals you have:
Disclosre agreement
*
To the best of my knowledge, all the preceding answers are true and correct. If deemed advisable, I grant permission for my physician to be contacted for information and advice. If I have any change in my health or medications that are not reported above, I will inform the doctor at my next visit.
Patient or Responsible Party's Name
*
Today's Date (mm/dd/yyyy)
*
Signature of Patient or Responsible Party
*
Our patients' privacy is of paramount importance to us. We do not store any patient information on our website or on our server and we will never share your information with a third-party without your consent.
