Manish Dhutia DMD, MS
Specialist in Orthodontics for Children and Adults
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General Dentist:
Referred By:
INSURANCE INFORMATION
Dental Insurance Company:
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If you do not have insurance, please input N/A.
Insurance Company Phone #:
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Subscribers Name:
Subscriber's DOB:
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Member ID # or SSN:
Group #:
MEDICAL HISTORY
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Yes
No
Any Heart Disease:
H.I.V. Positive or Aids:
Any Venereal Disease:
Any Bone Disease:
High or Low Blood Pressure:
Heart Murmer:
Hepatitis:
Diabetes:
Asthma or Hay Fever:
Tuberculosis:
Prolonged Bleeding:
Any Epilepsy or Seizure Disorder:
History of Fainting or Dizziness:
Is the Patient in Good Health?
Currently pregnant?
Is the Patient Under Medical Care?
Is the Patient Allergic to Anything?
(If yes, please specify below.)
Are you aware of any other disease,
condition, or problem not listed above
that we should know about?
(If yes, please specify below.)
Is the Patient Currently Taking Any Medications?
(If yes, please specify below.)
Please Specify/Add Additional Information Here:
DENTAL HISTORY
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Yes
No
Has the Patient Seen a General Dentist in the Last Year?
Any Pain, Clicking, or Discomfort in or Near the Ears?
Has the Mouth, Face, or Teeth been Injured by an Accident?
Frequent Headaches?
Are you Aware of any "Gum" Problems?
Have the Patient's Tonsils or Adenoids been Removed?
Thumb Sucking Habit?
Mouth Breathing?
Finger Nail Biting?
Tongue Thrusting?
Clench/Grinds Teeth?
In your own words, what is the orthodontic problem?
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