Welcome to our practice! Please take a few minutes to provide us with the following important information.
Confidential Patient Information
First Name:
Middle Name:
Last Name:
Preferred Name:
Gender:
Male
Female
Non-Binary
Transgender Male
Transgender Female
Other
Prefer Not to Answer
Pronouns:
He/Him
She/Her
They/Them
Other
Prefer not to say
Birthdate:
Street Address:
City:
Province:
Postal Code:
Phone Number:
Email:
How did you hear about our practice?
Occupation:
Do you play any sports, hobbies or musical instruments?
Family Information
Who is your emergency contact?
First Name:
Last Name:
Relationship:
Phone Number:
Do you have any family members who are patients at our office?
Are there any other family members who are interested in orthodontic treatment?
Insurance Information
Primary Insurance Plan:
Do you have dental or orthodontic insurance?
Yes
No
Not Sure
Policyholder Name:
Relationship to Patient:
Policyholder Date of Birth:
Employer:
Insurance Company:
Group/Policy #:
Subscriber/Member ID:
Secondary Insurance Plan:
Policyholder Name:
Relationship to Patient:
Policyholder Date of Birth:
Employer:
Insurance Company:
Group/Policy #:
Subscriber/Member ID:
Other Insurance Details
Please provide any other details about your insurance coverage:
Medical Information
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
General Practitioner Name:
Have you had any major illnesses, operations or hospitalizations in the last 5 years?
Do you have any artificial joints, heart valves or vascular grafts?
Have you ever been told you require antibiotics prior to dental treatment?
Do you take any medications? Please specify:
Are you allergic to any of the following?
Latex
Yes
No
Local anesthetics
Yes
No
Metals
Yes
No
Any Allergy Details
Are you allergic to any medications? Please specify:
Do you carry an EpiPen for any allergies?
Are you currently pregnant?
Are you a smoker?
For the following questions, please mark Yes, No or Don't Know:
Now or in the past, have you ever been diagnosed or treated for:
Asthma
Yes
No
Don't Know
Ear infections
Yes
No
Don't Know
Mouth breathing
Yes
No
Don't Know
Snoring/sleep apnea
Yes
No
Don't Know
Frequent colds
Yes
No
Don't Know
Frequent canker or cold sores
Yes
No
Don't Know
Sinus problems
Yes
No
Don't Know
Frequent headaches or migraines
Yes
No
Don't Know
Adenoid problems
Yes
No
Don't Know
Adenoid removal
Yes
No
Don't Know
Tonsilitis
Yes
No
Don't Know
Tonsil removal
Yes
No
Don't Know
Diabetes
Yes
No
Don't Know
Gland or endocrine problems
Yes
No
Don't Know
Liver problems
Yes
No
Don't Know
Hepatitis/Jaundice
Yes
No
Don't Know
Bone disorders
Yes
No
Don't Know
Cancer, tumors or growths
Yes
No
Don't Know
Congenital abnormalities
Yes
No
Don't Know
Seizures/Epilepsy
Yes
No
Don't Know
Tendency to get faint or dizzy
Yes
No
Don't Know
Blood disorders
Yes
No
Don't Know
Anemia
Yes
No
Don't Know
Prolonged bleeding
Yes
No
Don't Know
Blood transfusion
Yes
No
Don't Know
Pneumonia
Yes
No
Don't Know
Tuberculosis
Yes
No
Don't Know
Thyroid disorder
Yes
No
Don't Know
Kidney problems
Yes
No
Don't Know
Stomach problems
Yes
No
Don't Know
Autoimmune disorder
Yes
No
Don't Know
Rheumatic fever
Yes
No
Don't Know
Heart condition
Yes
No
Don't Know
Sexually transmitted infection
Yes
No
Don't Know
HIV
Yes
No
Don't Know
Mental illness, anxiety or depression
Yes
No
Don't Know
Autism spectrum disorder
Yes
No
Don't Know
Disordered eating
Yes
No
Don't Know
Please provide any other relevant details on medical history or family history:
Dental History
General Dentist and/or Office Name:
Last dentist visit:
Check-up frequency:
Frequency of brushing/flossing:
How has your past experience been with dental treatment?
Have you seen any dental specialists?
Periodontist
Endodontist
Oral Surgeon
Prosthodontist
None
Have you had any specialty procedures?
Root Canals
Large Fillings
Crowns
Bridges
None
Please provide any additional details:
Have you ever been diagnosed with gum or periodontal disease?
Are you aware of any outstanding dental treatment that needs to be completed?
Have you had any tooth extractions?
Do you have any missing or extra teeth?
Have you ever injured your head or face, or broken any teeth?
Do you have any other tooth concerns or issues?
Temperature sensitivity
Bleeding gums
Wisdom teeth
Irritation
Motivation for Orthodontic Treatment
Why are you seeking treatment?
Spaces
Crowding
Appearance
Jaw pain
Bite
Tooth wear
Referral
Please provide any specific details about your concerns:
Have you had previous orthodontic consultation or treatment?
Any speech difficulties or speech therapy?
Do you grind or clench your teeth?
Do you have any oral habits, such as thumb sucking or lip/nail biting?
Do you have any problems eating, chewing or swallowing?
Do you have any jaw issues?
Muscle soreness
Pain when opening or closing mouth
Clicking or popping noises
Current or previous treatment for TMJ
Please rate the following on a scale of 1 (not important) to 5 (very important)
Length of Treatment
1
2
3
4
5
Comfort During Treatment
1
2
3
4
5
Treatment Using Latest Technology
1
2
3
4
5
Clear/Invisible Treatment
1
2
3
4
5
Having a Low Down Payment
1
2
3
4
5
Having a Low Monthly Payment
1
2
3
4
5
Quality of Treatment
1
2
3
4
5
Starting Treatment As Soon as Possible
1
2
3
4
5
Do you have any hesitancy toward pursuing orthodontic treatment?
Is there any other information you would like us to know?
Patient Acknowledgement and Consents
Accuracy of Information
I certify that the information I have provided in this health history form is accurate and complete to the best of my knowledge. I understand that providing false, incomplete, or misleading information may affect my orthodontic care. I will promptly notify my orthodontist of any changes to the information provided in this form or my health status.
Use and Disclosure of Health Information
I understand that the information I provide will be kept confidential. I understand that the information I have provided in this health history form will be used by the orthodontic care team to evaluate, diagnose, and plan orthodontic treatment. I understand that this information will become a part of my medical record.
Electronic Communications
By providing my email address in this health history form, I am requesting that the practice use the email address I provide for communications related to my care and for general practice updates and I consent to such use.
Electronic Signature
By typing my name below and submitting this form, I am providing my electronic signature, which has the same legal effect as a handwritten signature.
Patient Name:
Date:
Form Completed by: