Confidential Patient Information

*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
(if over 18)
If patient is a minor, give parent's or guardian's name:
If patient is a minor, give names and ages of siblings?
Whom may we thank for referring you to our practice?
List any sports, hobbies, or musical instruments played:

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please respond to the following questions to let us know how to better assist you in treatment.

Teeth - If your teeth could be changed, how would you like them to change?
Face - If your facial appearance could be changed, what would you change?
Symptoms - If you want to reduce pain or discomfort, please be specific about its location.

Financial Party Information

*First Name:
Middle Name:
*Last Name:
Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*How long at this address?
*Do you rent or own your residence?
Previous Address (less than 3 years)
*Main Phone:
2nd/Cell Phone:
*Email:
Social Security #:
*Employer:
*Occupation:
Work Phone #:
*Length of Employment:
Spouse or Other Parent's First Name:
Middle Name:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
  (If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Emergency Information

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

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
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 headaches?
Neck/shoulder pain?
Frequent sore throats?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous root canal therapy?
Bad taste/mouth odor?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is there any dental work yet to be completed?
Please explain any 'Yes' answers (if none, please answer NA):
Have you had a TMJ screening?
Do you experience soreness in the muscles of your face or around your ears?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Please explain any 'Yes' answers (if none, please answer NA):

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?   
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Other:
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Sexually transmitted disease
Low blood pressure
Persistent cough
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
Please explain any 'Yes' answers (if none, please answer NA):

Patients Under 18

If patient is under the age of 18, please answer the following questions:
School:
(If not applicable put NA) 
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:
By signing my name, I acknowledge that I have completed the form and all answers are accurate to the best of my knowledge.



Acknowledgement of Receipt of Statement of Privacy Practices (HIPAA)
I acknowledge that I have reviewed the Statement of Privacy Practices for the office of Orthodontics Exclusively. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and responsibilities and duties of this office with the respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.
 
Orthodontics Exclusively reserves the right to change the privacy practices that are describe in the Statement of Privacy Practices. If the privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revision becomes effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
 
I agree to permit this patient’s photograph or first name to be displayed on office billboards, slideshows, and social media sites. I may advise you in writing if my wishes change. (Must answer)

 
In addition to the allowable disclosures in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health information to the persons indicated below.