PATIENT INFORMATION
*
Last Name
*
First Name
MI
Preferred
*
Birthdate:
*
Sex:
Male
Female
*
Street:
*
City:
*
State:
*
Zip:
Home Phone:
Cell Phone:
If Patient is a minor, name of person(s) with patient at exam:
Relationship to patient:
*
Have we previously treated any other family member?
No
Yes
If yes, whom?
What is expected from orthodontic treatment?
*
Patient's attitude toward braces:
Good
Bad
Indifferent
Whom may we thank for this referral?
How did you learn about our orthodontic office?
Family Member
Friend/Neighbor
Dentist
School
Insurance
Sign/Location
Internet
Website
Newspaper
Other
ACCOUNT INFORMATION
If Patient is a Minor:
Custodial Parent/Legal Guardian # 1
Last Name:
First Name:
MI:
Relationship to patient:
Address same as patient's
Street:
City:
State:
Zip:
Daytime Phone/Cell:
Do you rent or own?
Rent
Own
Employer:
E-Mail address:
Marital status:
How long have you been at this address?
Custodial Parent/Legal Guardian # 2
Last Name:
First Name:
MI:
Relationship to patient:
Address same as patient's
Street:
City:
State:
Zip:
Daytime Phone/Cell:
Do you rent or own?
Rent
Own
Employer:
E-Mail address:
If Patient is an Adult:
Employer
Occupation:
DaytimePhone/Cell:
E-Mail Address:
INSURANCE
Not Applicable
Name of Dental Insurance Company:
Insurance Company Phone Number:
Street:
City:
State:
Zip:
Name of Subscriber:
Subscriber's Date of Birth:
ID# or Social Security #:
EMERGENCY CONTACT (person not living with patient)
Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:
MEDICAL / DENTAL HISTORY
Family Dentist:
Address:
Date of last dental visit:
*
Is the patient under a physician's care?
No
Yes
If yes, for what?
List any medications now being taken:
For what reason?
List allergies to any medications:
Approximately how much has the patient grown in the last year?
Mother's Height:
Father's Height:
*
Has the patient reached puberty? (Boys: voice changing, Girls: menstruating)
No
Yes
Has the patient been diagnosed or treated for any of the following? (Check all that apply)
Neurodevelopmental Disorders (Autism, Autism Spectrum, Asperger's Syndrome, Etc.)
Behavioral Disorders (ADD, ADHD, ODD, OCD, Etc.)
Emotional Disorders (Depression, Anxiety, Bipolar, Etc.)
Rheumatic Fever
Blood Disorders
Lung Disorders
Bone Disorders
Osteoporosis
Heart Disease
Anemia
Tuberculosis
Arthritis
Cancer
Hepatitis
Asthma
Diabetes
Heart Murmur
AIDS/HIV Pos
Seizures
Abnormal Blood Pressure
Other
*
Does the patient require medication before dental visits?
No
Yes
*
Does the patient have a latex allergy?
No
Yes
*
Does patient have a persistent thumb or finger habit?
No
Yes
Until Age?
*
Is the patient a mouth breather?
No
Yes
*
Does the patient vomit, gag, or faint easily?
No
Yes
*
Does the patient experience headaches or neck aches, especially under stress?
No
Yes
*
Does the patient clench or grind the teeth?
No
Yes
*
Has the patient had any injuries involving the jaw or teeth?
No
Yes
*
Has the patient experienced any pain, popping, or locking of the jaw?
No
Yes
*
Has the patient ever been evaluated regarding a jaw problem?
No
Yes
*
Has the patient ever been treated for periodontal disease or has treatment been recommended?
No
Yes
*
Is patient missing any permanent teeth?
No
Yes
*
Does patient have any extra permanent teeth?
No
Yes
*
Has patient had any teeth removed by extraction?
No
Yes
*
Does the patient have a history of major illness?
No
Yes
*
Have tonsils and/or adenoids been removed?
No
Yes
*
Has the patient had any major operations?
No
Yes
*
Has the patient been involved in a serious accident?
No
Yes
*
Do the patient's gums bleed when brushed?
No
Yes
*
Has the patient ever had any speech problems/speech therapy?
No
Yes
*
Are there any problems, handicaps, or restrictions that may have a bearing on successful orthodontic treatment?
No
Yes
FEMALES: Are you pregnant or trying to become pregnant?
Yes
FEMALES: Has menstruation started? If so, at what age?
Yes
Is patient adopted? At what age?
*
Is patient/parent aware that appointments will infringe on work/school?
No
Yes
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 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.