Complete a patient form and prepare for your appointment today! Before you meet with our dentist in Moreno Valley, Los Angeles, Covina or West Covina, California, you can help Dr. Cristine Zapanta prepare for your visit. If you have any concerns or questions about the information you provide to Zapanta-Chavez Dentistry, call one of our conveniently located offices.

 

PATIENT DETAILS






















YesNoHas the patient been examined by an orthodontist before?
GUARDIAN #1 / INSURANCE INFORMATION













INSURANCE (IF APPLICABLE):




GUARDIAN #2 / INSURANCE INFORMATION
YesNo Is there a second guardian and / or additional insurance to add?













ORTHODONTIC INSURANCE (IF APPLICABLE):




SLEEP / AIRWAY ISSUES
YesNoDoes the patient tend to be a mouthbreather?
YesNoDoes the patient snore at night?
YesNoDoes the patient seem rested in the morning?
YesNoIs the patient often sleepy during the day?
YesNoHas the patient seen an Ear, Nose & Throat Specialist?
YesNoIs the patient using a sleep apnea device?
DENTAL/MEDICAL HISTORY

Please check if the patient has a history of the following medical conditions:

YesNoAcid Reflux
YesNoADHD/ADD
YesNoAIDS/HIV
YesNoAnemia
YesNoArthritis
YesNoAsthma
YesNoAutism
YesNoBone Disorders
YesNoCancer
YesNoCerebral Palsy
YesNoChest Pain
YesNoChronic Neck Pain
YesNoClicking of Jaw
YesNoJaw Pain
YesNoCold Sores/Herpes
YesNoDiabetes
YesNoDown Syndrome
YesNoEndocrine Problems
YesNoEmotional Disorders
YesNoEpilepsy
YesNoHeadaches
YesNoHeart Condition
YesNoHepatitis
YesNoEar Pain
YesNoImmune Problems
YesNoKidney Problems
YesNoLow Blood Pressure
YesNoMuscular Disorders
YesNoNervous Disorders
YesNoOrgan Transplant
YesNoOsteoporosis
YesNoPainful Chewing
YesNoPeriodontal Problems
YesNoProlonged Bleeding
YesNoRheumatic Fever
YesNoScoliosis
YesNoSeizures
YesNoSinus Problems
YesNoTMJ Problems
YesNoTuberculosis

YesNoDo your gums bleed when you brush?
YesNoIs the patient seeing any other dental specialists?
YesNoAny dental restorations needing to be completed?
YesNoHave there ever been any injuries to the face, mouth or chin?
YesNoHave you ever lost or chipped any teeth?
YesNoDo you have any pain or soreness around your face, neck or back?
YesNoIs any part of your mouth sensitive to temperature or pressure?
YesNoIs the patient currently pregnant?
YesNoHave adenoids been removed?
YesNoHave tonsils been removed?
YesNoCurrently taking any medications?
YesNoAre antibiotics necessary prior to treatment?
YesNoAllergies?
YesNoAny diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

YesNoCheek, tongue or lip biting
YesNoClenching Teeth
YesNoFingernail Biting
YesNoGrinding Teeth
YesNoTongue Sucking
YesNoThumb Sucking
YesNoTongue Thrusting
SIGNED CONSENT