Submit Your Patient Information and Health History Form Online to Parker Orthodontics! Please take a minute to complete your registration and health history information online! Complete this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will have your information downloaded and ready when you arrive for your first appointment. This website is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All of your personal health information is confidential, and will not be shared with anyone, aside from those involved in your treatment, without your consent.

Confidential Patient Information
*First Name: Middle Initial: *Last Name:	*Birthdate:   *Gender: Male Female Nickname:
*Address: *City: *State: *Zip: *Cell Phone: 2nd/Cell Phone: Email: If patient is a minor, give parent's or guardian's name: If patient is a minor, who does patient live with?    Father Mother Mother & Father Stepmom/Dad Stepdad/Mom Grandparent(s) Other Please list the names of any friends or family currently in the practice: School: Grade: List any sports, hobbies, or musical instruments played: General Dentist Name: Whom may we thank for referring you to our practice?

Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name: *Last Name: Marital Status:   Single Married Divorced Partner *Cell Phone: 2nd/Cell Phone: *Email:   *Birthdate:   Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other	Check if address is the same as patient *Address: *City: *State: *Zip: Social Security #: Employer: Occupation: Work Phone #:
*Spouse or Other Parent's First Name: *Last Name: Marital Status:   Single Married Divorced Partner *Cell Phone: 2nd/Cell Phone: *Email: *Birthdate:   Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other	Check if address is the same as patient *Address: *City: *State: *Zip: Social Security #: Employer: Occupation: Work Phone #:

Emergency Information
Name of nearest relative not living with you:
Phone: Relationship to Patient: Father Grandparent Guardian Mother Parents Spouse Step Father Step Mother Other

Dental Insurance Information     Primary Dental Insurance Policy Holder's Name: Insurance Company: Subscriber ID #: Group No.: Birthdate:   Insurance Co. Address: City: State: Zip: Insurance Co. Phone No.: Policy Holder's Employer: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Do you have dual dental coverage? NoYes   (If yes, complete information below) Secondary Dental Insurance

Policy Holder's Name: Insurance Company: Subscriber ID #: Group No.: Birthdate:   Insurance Co. Address: City: State: Zip: Insurance Co. Phone No.: Policy Holder's Employer: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other

Medical History
Patient Health:  Excellent Good Fair Poor
NoYes    Has there been any change in the patient's general health within the last year?
If so, what changed?
NoYes     Do you take any medications for osteoporosis such as Fosamax, Boniva or Actonel?
Allergies or drug reaction to:
NoYes Latex NoYes Penicillin or other antibiotics NoYes Sulfa drugs NoYes Aspirin, Ibuprofen, Tylenol NoYes Local anesthetics NoYes Codeine or other narcotics   NoYes Peanuts/Nuts NoYes Metal/Nickel Allergy List any other allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
NoYes Heart Murmur NoYes Damaged or artificial heart valves NoYes Congenital Heart Defect NoYes Heart Disease NoYes Rheumatic Fever NoYes Hepatitis NoYes Prolonged/Abnormal Bleeding NoYes Handicaps/Disabilities NoYes Arthritis / Joint problems NoYes Large Tonsils NoYes Sinus trouble NoYes Bone fractures/trauma to face/jaw NoYes Prosthetic joints NoYes Chronic fatigue	NoYes Diabetes NoYes Growth Problems NoYes Thyroid / Endocrine Problems NoYes Nervous Disorders NoYes Bone Disorders/Bone Loss NoYes Seizures / Epilepsy / Neurological Disease NoYes Treated for Emotional Problems NoYes Asthma NoYes Persistent swollen neck glands NoYes Chronic Ear Aches NoYes Do you experience soreness in the muscles of your face or around your ears? NoYes FEMALES: Are you pregnant NoYes Has the patient grown in the past year or has their shoe size changed recently
If any of the above medical questions were answered 'Yes' , please explain:
Is there any condition affecting the patient's health other than those mentioned? If yes, please list:

Dental History

Dentist Name:	Check-up Frequency:   Once per year Twice per year More than twice a year Never Emergencies only
NoYes             Is all dental work completed at this time?
NoYes             Does the Patient need to premedicate prior to dental visit?
NoYes             Has the patient had an orthodontic consult or treatment?
If so, when?
Has either biological parent ever had orthodontic treatment?    Don't Know Yes No
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.
NoYes Speech problems/therapy? NoYes Grind or clench teeth? NoYes Oral habits (thumb/finger sucking, lip/nail biting)? NoYes Injury to face, jaw, teeth or mouth? NoYes Pain, tenderness or noise in either jaw? NoYes Frequent headaches? NoYes Chipped or injured permanent teeth? NoYes Teeth sensitive to hot or cold? NoYes Previous periodontal (gum) treatment? NoYes Abnormal swallowing (tongue thrust)?	NoYes Snores during sleep? NoYes Mouth breathing, difficulty breathing? NoYes Any missing or extra permanent teeth? NoYes Thumb or finger habit as a child? NoYes Jaw Fractures, cysts, mouth infections? NoYes Bleeding gums? NoYes Other periodontal (gum) problems? NoYes Frequent canker sores or cold sores? NoYes Problems with food trapped between teeth? NoYes Do you notice clicking or popping in your jaw joint? NoYes Do you have a history of jaw joint problems? NoYes Strong gag reflex?
If any of the above dental questions were answered 'Yes', please explain:

NoYes   Would the patient be willing to wear braces if necessary to correct the problem? NoYes   Are you interested in Invisalign? Is there any reason why treatment should not start immediately? I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my      knowledge. 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 to this history record or medical or dental status, I will inform the practice.