Confidential Patient Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
Employer/School:
*Home Phone:
Cell Phone:
Email:
Social Security #:
Work/School Phone:
If patient is a minor, please answer the following
Father's Name:
Mother's Name:
Address:
Address:
City:
City:
State:
State:
Zip:
Zip:
Home Phone
Home Phone:
Cell Phone:
Cell Phone:
E-mail:
E-mail:
Marital Status:
Marital Status:
Employer:
Employer:
Work Phone:
Work Phone:
Who does patient live with?
Select...
Father
Mother
Mother & Father
Other
Please specify:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
How did you hear about our practice?
Select
Dentist
Family/Friends
Website
Facebook
Drive by/Sign
Advertisement
Other
Please specify:
Emergency Information
Name of nearest relative not living with you:
Address:
City
State:
Zip:
Phone:
Relationship to Patient:
Select...
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
Marital Status:
Select...
Single
Married
Partnered
Widowed
Divorced
Separated
How long at this address?
*Main Phone:
Cell Phone:
Email:
*Birthdate:
Relationship to Patient:
Select...
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Spouse's First Name:
Middle Initial:
Last Name:
Social Security #:
Employer:
Occupation:
Birthdate:
Length of Employment:
Work Phone #:
Relationship to Patient:
Select...
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Dental Insurance Information
Primary Dental Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Select...
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Select...
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Dental History
Dentist Name:
Is all dental work completed?
Yes
No
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
By whom?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
No
Yes
Speech problems/therapy
No
Yes
Clench or grind teeth
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)
No
Yes
Injury to face, jaw, teeth or mouth
No
Yes
Discomfort from teeth or gums
No
Yes
Pain, tenderness or noise in either jaw
No
Yes
Frequent headaches
No
Yes
Neck/shoulder pain
No
Yes
Chipped or injured permanent teeth
No
Yes
Previous root canal therapy
No
Yes
Bad taste/mouth odor
No
Yes
Abnormal swallowing (tongue thrust)
No
Yes
Mouth breathing
No
Yes
Snores during sleep
No
Yes
Apprehensive about dental care
No
Yes
Jaw fractures, cysts, mouth infections
No
Yes
Frequent canker sores or cold sores
No
Yes
Problems with food trapped between teeth
No
Yes
Previous periodontal (gum) treatment
No
Yes
Teeth sensitive to hot or cold
No
Yes
Clicking/popping/pain in TMJ(jaw joint)
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
No
Yes
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescirption):
No
Yes
FEMALES: Are you pregnant
Allergies or drug reaction to:
No
Yes
Latex
No
Yes
Nickel
No
Yes
Medications
If yes to any allergies, please explain in detail or list anything not mentioned above.
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
No
Yes
Heart Murmur
No
Yes
Heart Disease
No
Yes
Angina
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Handicaps/Disabilities
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Tuberculosis or Lung Disease
No
Yes
Cancer
No
Yes
ADD/ADHD
No
Yes
Radiation Treatment
No
Yes
Hormone Therapy
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Treated for Emotional Problems
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
Persistent swollen neck glands
No
Yes
Low blood pressure
No
Yes
Persistent cough
If any of the above medical questions were answered 'Yes' , please explain:
Does the patient need to premedicate prior to dental visit?
No
Yes
If yes, please explain.
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I understand that where appropriate, credit bureau reports may be obtained.