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?
No
Yes
(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
No
Yes
Has there been any change in the patient's general health within the last year?
If so, what changed?
No
Yes
Do you take any medications for osteoporosis such as Fosamax, Boniva or Actonel?
Allergies or drug reaction to:
No
Yes
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Codeine or other narcotics
No
Yes
Peanuts/Nuts
No
Yes
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.
No
Yes
Heart Murmur
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital Heart Defect
No
Yes
Heart Disease
No
Yes
Rheumatic Fever
No
Yes
Hepatitis
No
Yes
Prolonged/Abnormal Bleeding
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Large Tonsils
No
Yes
Sinus trouble
No
Yes
Bone fractures/trauma to face/jaw
No
Yes
Prosthetic joints
No
Yes
Chronic fatigue
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Thyroid / Endocrine Problems
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Treated for Emotional Problems
No
Yes
Asthma
No
Yes
Persistent swollen neck glands
No
Yes
Chronic Ear Aches
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
FEMALES: Are you pregnant
No
Yes
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
No
Yes
Is all dental work completed at this time?
No
Yes
Does the Patient need to premedicate prior to dental visit?
No
Yes
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.
No
Yes
Speech problems/therapy?
No
Yes
Grind or clench teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Snores during sleep?
No
Yes
Mouth breathing, difficulty breathing?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Thumb or finger habit as a child?
No
Yes
Jaw Fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Other periodontal (gum) problems?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Problems with food trapped between teeth?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Strong gag reflex?
If any of the above dental questions were answered 'Yes', please explain:
No
Yes
Would the patient be willing to wear braces if necessary to correct the problem?
No
Yes
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.