Confidential Patient Information
*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Home Phone:
If patient is a minor, give parent's or guardian's name:
Names and ages of any other children in the family:
List any sports, hobbies, or musical instruments played:
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:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (less than 3 years)
Do you rent or own your home?
Rent
Own
Other
Email:
*Cell Phone:
Social Security #:
Work Phone #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Cell Phone:
Work Phone #:
Employer:
Occupation:
Length of Employment:
Dentist Information
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Brush teeth daily?
Floss teeth daily?
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Insured's Birthdate:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Insured's Birthdate:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the Patient need to premedicate prior to dental visit?
No
Yes
What is the patient's main orthodontic concern?
Please select if the patient has had any of the conditions listed below either now or in the past. Check all that apply.
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent sore throats?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Bad taste/mouth odor?
Abnormal swallowing (tongue thrust)?
Numerous fillings?
Mouth breathing?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Jaw Fractures, cysts, mouth infections?
Other periodontal (gum) problems?
If any of the above dental questions were selected, please explain:
Do you have a history of jaw joint problems?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction:
Please check all that apply if the patient has had any of the conditions listed below either now or in the past.
High or Low Blood Pressure
Pain in chest, shortness of breath
Blood disorders, anemia
Blood test with unusual result
Abnormal bleeding, prolonged healing, bruise easily
Asthma, hay fever
Fainting spells, seizures, blackouts, epilepsy
Jaundice, liver disease
Arthritis
Hepatitis
Venereal disease
AIDS
Kidney troubles
Tuberculosis, other lung disease
Severe persistent cough
Diabetes, tumors, cancer
Radiation treatment for a tumor or other growth
Sores that do not heal within one week
Unusual weight gain or loss
Sensitive or allergic to medications or drugs
Allergic to any metals or jewlery
Pregnant
If any of the above medical questions were selected , please explain:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. 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 later to this history record or medical or dental status, I will inform the practice.
I understand that where appropriate, credit bureau reports may be obtained.