Patient Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
Email:
Patient's Email
Responsible Party Email
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell/Other Phone:
Work Phone: (if applicable)
Marital Status: (if applicable)
Single
Married
Partnered
Divorced/Separated
Widowed
DL: (if applicable)
Employer: (if applicable)
Occupation: (if applicable)
How long there? (if applicable)
Whom may we thank for referring you to our practice?
Dentist Name:
Last Visit Date:
Dentist's Phone Number:
Relative or friend not living with you (in case of emergency):
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Other family members seen by us:
Parents name seeking treatment / Person responsible for Account
*First Name:
Middle Initial:
*Last Name:
Employer:
Work Phone:
Social Security #:
Spouse Name:
Primary Insurance
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's DOB:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Secondary Insurance
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's DOB:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Co. Phone No.:
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure payment of benefits. And I assign directly to the doctor all insurance benefits otherwise payable to me.
Medical History
Does patient have a personal physician?
No
Yes
Physician Name:
Date of last Physical:
Phone:
Patient Health:
Good
Excellent
Fair
Poor
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Do you smoke/vape or use tobacco?
No
Yes
Have you had any metal rods, pins or implants?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Have you ever taken Fosamax or any other bisphosphonate?
No
Yes
Has puberty begun?
No
Yes
FEMALES: Has menstruation begun?
No
Yes
Please select YES or No for the Following Questions - Do Not Leave Blank
Abnormal Bleeding
No
Yes
High Blood Pressure
No
Yes
Arthritis
No
Yes
Liver Disease
No
Yes
Blood Transfusion
No
Yes
Mitral Valve Prolapse
No
Yes
Diabetes
No
Yes
Radiation Treatment
No
Yes
Seizures
No
Yes
Fainting Spells
No
Yes
Sinus Problems
No
Yes
Thyroid Problems
No
Yes
Heart Attack/Surgery
No
Yes
Hepatitis
No
Yes
Herpes/Fever Blisters
No
Yes
Alcohol/Drug Abuse
No
Yes
Kidney Problems
No
Yes
Asthma
No
Yes
Lupus
No
Yes
Colitis
No
Yes
Psychiatric Problems
No
Yes
Emphysema
No
Yes
Stroke
No
Yes
Frequent Headaches
No
Yes
Hay Fever
No
Yes
Ulcers
No
Yes
Venereal Disease
No
Yes
AIDS
No
Yes
Anemia
No
Yes
Artificial Bones/Joints/Valves
No
Yes
Low Blood Pressure
No
Yes
Cancer/Chemotherapy
No
Yes
Pacemaker
No
Yes
Congenital Heart Defect
No
Yes
Rheumatic/Scarlet Fever
No
Yes
Shingles
No
Yes
Sickle Cell Disease/Traits
No
Yes
Autism/Aspergers
No
Yes
Tuberculosis
No
Yes
Heart Murmur
No
Yes
Hospitalized for any reason
No
Yes
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following:
Aspirin
No
Yes
Penicillin or other antibiotics
No
Yes
Codeine
No
Yes
Jewelry/Metals
No
Yes
Dental anesthetics
No
Yes
Latex
No
Yes
Plastics
No
Yes
Nuts
No
Yes
Other:
No
Yes
Please list any other drugs/materials that you are allergic to:
What are the main goals that you would like orthodontics to accomplish?
Have you ever had any orthodontic treatment?
Yes
No
Have you ever had a serious/difficult problem associated with Dental work?
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ? TMD?)
Yes
No
Your current dental health is:
Good
Fair
Poor
Are you missing any permanent teeth including wisdom teeth?
Yes
No
Have you ever had an injury to your:
Mouth
Chin
Teeth
Do you have any speech problems?
Do you generally breathe through your mouth?
Yes
No
If yes, when?
while awake
while asleep
Do you grind your teeth either during the day or night?
Yes
No
Do you have any oral habits (i.e. thumb sucking)?
Yes
No
If yes, 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.