Confidential Patient Information

*First Name:
MI:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Preferred phone contact (cell or home):
*Birthdate:
Email:
Social Security #:
If patient is a minor, please give parent's or guardian's name:
*Whom may we thank for referring you to our practice?
Please list any sports, hobbies, or musical instruments played:

Confidential Reponsible Party Information

*First Name:
Middle Initial:
*Last Name:
*Marital Status:
*Residence:
*City:
*State:
*Zip:
*Own or Rent
Mailing Address:
City:
State:
Zip:
*How long at address?
Preferred phone contact (cell or home):
Work Phone:
Email:
*Previous Address (less than 3 years)
*Social Security #:
*Birthdate:
Relationship to Patient:
*Employer:
*Occupation:
*Length of Employment:
Spouse's Name:
Middle Initial:
Last Name:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Social Security #:
Birthdate:
Work Phone #:
Email:

Insurance Information

Policy Holder's Name:
Social Security #:
Policy Holder's Employer:
Insurance Company:
Group No.:
Union Local #:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Do you have dual dental coverage?
     (If yes, complete information below)
Policy Holder's Name:
Social Security #:
Policy Holder's Employer:
Insurance Company:
Group No.:
Union Local #:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Medical and Dental History

Please tell us your main concerns and reason for being here in detail (please be specific if you can)?
Dentist Name:
Last Dental Visit:
Do you need a referral to a local dentist?
Is there any dental work yet to be completed         orthodontic treatment?   
Has the patient ever had orthodontic treatment?
If yes, please indicate WHEN and HOW LONG?
Indicate patient's feelings toward orthodontic treatment
Are antibiotics necessary when you get your teeth cleaned?
Physician Name:
Last Physical Exam:
Is the patient currently under the care of a physician?
If yes, please explain
List any medications/supplements/vitamins being taken at this time:
List any drugs/things that the patient is allergic or has a reaction to:
HAS THE PATIENT EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?
Abnormal Bleeding
HIV/AIDS
Diabetes
Plastic/Metal Allergy
Heart Problems
Asthma
Latex Allergy
Cancer or Tumor
Hepatitis
Epilepsy/Seizures
Fainting/Dizziness
Anemia
Thyroid Problems
Pregnant Now
Tuberculosis
Kidney/Liver Problems
Hemophilia
Venereal Disease
Heart Murmur
High Blood Pressure
Sleep Apnea
Snore
Acid Reflux
Other Condition
HAS THE PATIENT EVER HAD ANY OF THE FOLLOWING DENTAL PROBLEMS?
Thumb Sucking Now/Past
Finger Sucking
Mouth breathing?
Chew Tobacco
Smoke Tobacco
Cavities Present
Jaw Trauma
Tooth Trauma
Missing Teeth?
Tonsils/Adenoids Problems
Lip/Tongue Biting
Tongue_Thrusting
Grinding_Of_Teeth
Clenching_Of_Teeth
Difficulty Chewing
Noise/Clicking of Jaw Joints
TMJ Problems
Frequent Sore Throats
Headaches
Frequency/Location of Headaches:
Please explain any medical or dental conditions marked 'Yes' above or any condition the patient may have but is not mentioned in the above list:
* I have reviewed a copy of the Dr. John Digiovanni Orthodontics Notice of Privacy Practices. Click here to review