Patient Information
*Patient's Name:
*Address:
*Home Phone:
*Birthdate:
Social Security #:
If patient is a minor, give parent's or guardian's name:
Whom may we thank for referring you to our office?
Responsible Party Information
Name:
Marital Status
Single
Married
Seperated
Divorced
Widowed
Residence:
Mailing address is the same as above.
Mailing Address:
How long at this address?
Home Phone:
Work Phone:
Previous Address: (if less than 3 years)
Social Security #:
Birthdate:
Relationship to Patient:
Select
Parent
Self
Spouse
Guardian
Employer:
Occupation:
No. Years Employed:
Spouse's Name:
Relationship to Patient:
Select
Parent
Self
Spouse
Guardian
Employer:
Occupation:
No. Years Employed:
Social Security #:
Birthdate:
Work Phone:
Orthodontic Insurance Information
Policy Holder's Name:
Insurance Company:
Insured's Soc. Sec. #
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Insurance Company:
Insured's Soc. Sec. #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Health History
What are the main concerns that you would like orthodontics to accomplish?
Has the patient ever been evaluated or had orthodontic treatment before?
Yes
No
Have there been any injuries to the face, mouth, teeth, or chin?
Yes
No
List any musical instruments played:
Have adenoids or tonsils been removed?
Yes
No
Has the patient been informed of any missing or extra permanent teeth?
Yes
No
Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?
Yes
No
Does the patient brush his/her teeth daily?
Yes
No
Does the patient floss his/her teeth daily?
Yes
No
Patient's Physician:
Phone #:
Patient's Dentist:
Date of last visit:
Is the patient currently under the care of a physician?
Yes
No
Has puberty begun?
Yes
No
Has menstruation begun? (girls)
Yes
No
Please describe the patient's current health:
Good
Fair
Poor
Please list all drugs the patient is currently taking:
Please list all drugs/things the patient is allergic to:
Has the patient ever had any of the following medical problems?
Abnormal Bleeding
Yes
No
Allergies to any drugs
Yes
No
Allergic to Latex/Metal
Yes
No
Allergic to Plastic
Yes
No
Any hospital stays
Yes
No
Asthma
Yes
No
Cancer
Yes
No
Congenital Heart Defect
Yes
No
Convulsions/Epilepsy
Yes
No
Diabetes
Yes
No
Handicaps/Disabilities
Yes
No
Hearing Impairment
Yes
No
Heart Murmur
Yes
No
Hemophilia
Yes
No
Hepatitis
Yes
No
HIV+/AIDS
Yes
No
Kidney/Liver Problems
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Tuberculosis (TB)
Yes
No
Please discuss any medical problems that the patient has had:
Does the patient have any of the following habits?
Clenching/Grinding Teeth
Yes
No
Lip Sucking/Biting
Yes
No
Mouth Breathing
Yes
No
Nail Biting
Yes
No
Nurse Bottle Habits
Yes
No
Speech Problems
Yes
No
Thumb/Finger Sucking
Yes
No
Tongue Thrust
Yes
No
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services the patient may need.