*First Name:
MI:
*Last Name:
Name preferred to be called:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Primary Phone:
Secondary Phone:
*Email:
 
Social Security #:

If patient is a minor, give parent's or guardian's name:
*Who does the patient live with?
What school does the patient attend?
Is the patient adopted?
If yes, okay to discuss in front of patient?
*First Name:
Middle Initial:
*Last Name:
*Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*How long at this address?
Previous Address (less than 3 years)
*Email:
*Primary Phone:
Secondary Phone:
Work Phone #:
Social Security #:
*Employer:
*Occupation:
*Length of Employment:

If applicable, complete for Spouse/Other parent
First Name:
Middle Initial:
Last Name:
Address:
City:
*State:
*Zip:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Cell Phone #:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
City:
State:
Zip:
Policy Holder's Cell #:
Policy Holder's Birthdate:
Insurance Company:
Insurance State:
Insurance Co. Phone No.:
Subscriber ID #:
Group #:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
City:
State:
Zip:
Policy Holder's Cell #:
Policy Holder's Birthdate:
Insurance Company:
Insurance State:
Insurance Co. Phone No.:
Subscriber ID #:
Group #:
Emergency Contact:
Phone:
Dentist Name:
Last Dental Visit:
*Does the Patient need to premedicate for a medical condition prior to dental visit?
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.
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Frequent headaches?
Jaw pain/tenderness?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Mouth breathing?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of Last Physical:
Patient Health:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
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-prescription):

Allergies or drug reaction to:
Latex
Penicillin, Sulfa or other antibiotics
Metal Allergy
Aspirin, Ibuprofen, Tylenol, Codeine or other narcotics
Please give more detail to any "Yes" answered questions from above and list any other allergies:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Condition: murmur, damage, valves, defects or disease
Rheumatic Fever
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
High or Low Blood Pressure
Blood disorder or bleeding disorders (hemophilia, anemia, prolonged bleeding)
HIV/AIDS
Tonsils/Adenoids Removed or Large Tonsils
Handicaps/Disabilities
Arthritis / Joint problems
Prosthetic joints
Bone Disorders/Bone Loss
Currently taking or have taken Bisphosphonates (Fosamax, Boniva)
Sinus trouble
Substance abuse problem (past or present)
Chronic fatigue
Diabetes
Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine / Growth Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Nervous / Emotional Problems or Disorders
Seizures / Epilepsy / Neurological Disease
Asthma
Respiratory problems / Emphysema / Tuberculosis - Lung Disease
Persistent swollen neck glands
Sexually transmitted disease
Has patient begun puberty:
FEMALES: Are you pregnant
If any of the above medical questions were answered 'Yes' , please explain:
  *I hereby acknowledge that I have read and received the HIPAA policies of Orthodontic Associates.

Release of Information

THIS RELEASE OF INFORMATION WILL REMAIN IN EFFECT UNTIL TERMINATED BY ME IN WRITING

Messages

Please call:
If unable to reach me:
 
The best time to reach me is (day)
 between (time)
*Who is filling the Health History in relation to the patient?
*Relationship to patient: