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Stars Orthodontics

Dr. Khaled A. Sharaf

B.Sc., DMD, MBA, M.Sc., FRCD(C) | Certified Specialist in Orthodontics

Gender:
Do you have dental insurance?
Are you covered by any other dental insurance?

Medical History

Are you in good health?
Have you had any serious illnesses/hospitalizations?
WOMEN: Are you pregnant?

Dental History

Have you ever had any injuries to the face, mouth or teeth?
Have you ever been treated for a jaw joint problem, including surgery?
Have you ever sucked your thumb or finger? Until what age?
Do you have any speech problems?
Do you have any habits (nail biting, lip biting)?
Do you have frequent canker or cold sores?
Are you a mouth breather? While asleep? While awake?
Have you been informed of any missing or extra permanent teeth?
Do you grind or clench your teeth?
Do you have difficulty opening and/or closing your jaw?
Have you ever had a previous orthodontic examination?
Are you apprehensive towards dental visits?
Have any other family members had braces or orthodontic treatment?

For Adults

Patient Biographical Information

For Children

Patient Biographical Information

Gender:

Parent/Guardian 1:

Parent/Guardian 2:

Parent/Guardian 3:

Parent/Guardian 4:

Medical History

Is your child in good health?
Has your child had any serious illnesses/hospitalizations?
Has the patient reached puberty?
Girls: Has menstruation started?
Boys: Has voice changed yet?

Dental History

Has your child ever had any injuries to the face, mouth or teeth?
Has your child ever been treated for a jaw joint problem, including surgery?
Does your child have any speech problems?
Does your child have any habit (nail biting, lip biting)?
Is your child a mouth breather? While asleep? While awake?
Have you been informed of any missing or extra permanent teeth?
Is your child apprehensive towards dental visits?
Does your child want orthodontic treatment?
Has your child ever sucked his/her thumb or finger? Until what age?
Does your child have frequent canker or cold sores?
Has your child ever had a previous orthodontic examination?
Have any other family members had braces or orthodontic treatment?