Patient Health History

* First Name:
MI:
* Last Name:
* Birthdate:
* Gender:
Nickname:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone:
Email:
School/Employer:
Grade/Job Title:
Spare Time Activities:
Whom may we thank for referring you to our practice?
If Friend or Other, please tell us who:
How would you like appointment reminders?
Please list number to text and/or email address:
* Do you have Dental Insurance?
    If yes, please fill out and submit the insurance form.

Mother's Information

If patient is under 18 please complete this section.

Title:
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Occupation:
Employer:
Work Phone #:

Father's Information

If patient is under 18 please complete this section.

Title:
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Occupation:
Employer:
Work Phone #:

Financial Responsible Party Information

Name one person only. Your account will be set up in this name.

* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone:

Dental Information

What would you like to change about your smile?
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had a previous orthodontic consult or treatment?
If so, when?
Has anyone in the immediate family had treatment?
If so, who and when?

Dental History

* Requires Premedication?
For what?
* Clenching or Grinding of Teeth?
* Thumb/Finger Sucking?
Until age?
* Difficulty Opening Mouth Wide?
* Bites Nails?
* Clicking or Popping of the Jaw?
* Speech Problems/Therapy?
* Headaches?
How Often?    
* Snoring?
* Injury to face, jaw, teeth or mouth?
What? When?
* Mouth breathing?
* Ear Infections?
* Sinus Pressure/Problems?
* Frequent Cold Sores?
* Frequent sore throats?
* Frequent Canker Sores?
* Removal of Tonsils/Adenoids?
Which?    
* Food Frequently Lodged in Between Teeth?
If any of the above dental questions were answered 'Yes' , please explain:

Medical Information

Physician Name:
City:
List any medications currently being taken:
For What?
List any medication allergies or sensitivities:
* Latex Allergy?
* Metal Allergy (ie Nickel)?
* Do you currently smoke?
Pregnant at this time?

Medical History

* Arthritis?
* Heart Attack/Stroke?
* Bone Disorders?
* Ulcers/Colitis/Diverticulitis?
* Kidney/Bladder Infection?
* Auto Immune Disorder?
* Seizures/Epilepsy?
* Nervous Disorders?
* Mental Health/Depression/Anxiety Illness?
* High/Low Blood Pressure?
* Hepatitis?
Specify type:
* Blood Disease?
* Heart Defects/Murmur?
* Cancer/Tumor?
* Chemotherapy/Radiation?
* Fainting?
* Tuberculosis?
* Osteoporosis?
* Anemia, Excessive Bleeding/Bruising?
* Asthma or Hay Fever?
* Hearing Impaired?
* HIV/AIDS?
* Thyroid or Parathyroid Disorders?
* Do you or have you ever taken a Bisphosphonate drug such as Pamidronate (Aredia), Zoledronate (Zometa), Alendronate (Fosamax)?
If yes, when?
If any of the above medical questions were answered 'Yes' , please explain:
Any other condition or problem we should be aware of?