Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Mother/Guardian’s Name:
Father/Guardian’s Name
Please list the names of immediate family members that have been to this Practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Motivation for Seeking Treatment
Please help us to understand your concerns or desires by sharing the following information; please be specific.
General Concerns:
Teeth/Smile - Is there anything about your smile or teeth that you'd like to change?
Symptoms:
Dental Insurance Information
Policy Holder’s Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder’s Name:
Policy Holder’s Relationship:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder DOB:
Do you have dual dental coverage? (If yes, complete information below)
Yes
No
Policy Holder’s Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder’s Name:
Policy Holder’s Relationship:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder DOB:
Emergency Contact Information
Name:
Address:
City:
State:
Zip:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
In case of emergency, is it OK to release medical/dental information?
Yes
No
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
Yes
No
If so, when?
Have your teeth changed in the last five years, become shorter, thinner, or worn? If yes, please explain:
Do you wear/have you ever worn a bite appliance?
Yes
No
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech concerns/therapy?
Yes
No
Snores during sleep?
Yes
No
Grind or clench teeth?
Yes
No
Diagnosis of Sleep Apnea?
Yes
No
Injury to face, jaw, teeth or mouth?
Yes
No
Wake up tired after a full night of sleep?
Yes
No
Neck/shoulder pain?
Yes
No
Pain, tenderness or noise in either jaw?
Yes
No
Discomfort from teeth or gums?
Yes
No
Prosthetic joints?
Yes
No
Artificial heart valves?
Yes
No
Requires premedication for dental visits?
Yes
No
Oral habits (thumb/finger sucking, lip/nail biting)?
Yes
No
Any missing or extra teeth?
Yes
No
Dry mouth (Sjogren's syndrome?
Yes
No
Frequent headaches?
Yes
No
Sensitive gagging reflex?
Yes
No
Mouth breathing?
Yes
No
If any of the above dental questions were answered 'Yes' or you have any other dental concerns, please explain?
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
List any allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
Yes
No
Growth Problems
Yes
No
Tuberculosis/Lung Disease
Yes
No
Endocrine/Thyroid Problems
Yes
No
Pneumonia
Yes
No
Hormone Therapy
Yes
No
History of smoking
Yes
No
Tonsils/Adenoids Remove
Yes
No
Liver Disease
Yes
No
Bone Disorder/Bone Loss
Yes
No
Heart Disease
Yes
No
Past or Present treatment for Osteoporosis/osteopenia (Fosamax)
Yes
No
Heart Attack/Stroke
Yes
No
Seizures/Epilepsy
Yes
No
Heart Murmur
Yes
No
Faints easily
Yes
No
Congenital Heart Defect
Yes
No
Inflamatory Rheumatism
Yes
No
Hypertension/High Blood Pressure
Yes
No
Arthritis
Yes
No
Hemophilia
Yes
No
Handicaps/Disabilities
Yes
No
Prolonged Bleeding/Transfusion
Yes
No
Asthma
Yes
No
Anemia
Yes
No
ADHD
Yes
No
Heptitis
Yes
No
Anxiety with new experiences
Yes
No
HIV/AIDS
Yes
No
Autism/autism spectrum disorder/Aspergers/PPD
Yes
No
Metal Allergy
Yes
No
Latex Allergy
Yes
No
Herpes (Oral cold sores)
Yes
No
Cancer
Yes
No
Received Radiation Treatment
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
List any surgeries:
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone:
By typing my name below, 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/her staff responsible for any error 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.
Signature: