Patient Information
First Name:
MI:
Last Name:
Preferred Name:
Birthdate:
Age:
Sex:
Male
Female
S.S.#:
Marital Status:
Single
Married
Widowed
Separated
Divorced
Address:
City:
State:
Select
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Home Phone #:
Main Cell #:
Other Family Members Treated in This Office:
Child Patients: Siblings' Names and Birthdates:
Referred By:
Current Dentist:
Address:
Phone #:
Current Physician:
Address:
Phone #:
Primary Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
MI:
Last Name:
Birthdate:
Address:
City:
State:
Select
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Home #:
Cell #:
Work #:
Email:
S.S.#:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Employer:
Dental Ins. Co. Name:
Address:
Phone #:
ID #:
Group #:
Orthodontic Coverage?
Yes
No
Secondary Responsible Party Information
First Name:
MI:
Last Name:
Birthdate:
Address:
City:
State:
Select
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Home #:
Cell #:
Work #:
Email:
S.S.#:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Employer:
Dental Ins. Co. Name:
Address:
Phone #:
ID #:
Group #:
Orthodontic Coverage?
Yes
No
Medical History
Heart Murmur
Yes
No
Arthritis
Yes
No
Congenital Heart Defect
Yes
No
Skin Disorder
Yes
No
Rheumatic Heart Disease
Yes
No
Endocrine Disorder
Yes
No
Prosthetic Heart Valve
Yes
No
Convulsions/Epilepsy
Yes
No
Previous Endocarditis
Yes
No
Abnormal Bleeding/Hemophilia/Anemia
Yes
No
Angina/Heart Attack/Stroke
Yes
No
Kidney Problems
Yes
No
Cancer
Yes
No
Bone Disorders
Yes
No
Diabetes
Yes
No
Previous Operations
Yes
No
HIV/AIDS
Yes
No
Previous Hospitalizations
Yes
No
Asthma/Hayfever
Yes
No
Handicap/Disability
Yes
No
Liver Disorder/Hepatitis
Yes
No
Emotional Problems
Yes
No
Tuberculosis/Pneumonia
Yes
No
Premature Birth
Yes
No
Nickel/Metal Allergy
Yes
No
Hearing Impairment
Yes
No
Latex Allergy
Yes
No
Current Pregnancy
Yes
No
Please indicate any medical conditions not listed above:
Please elaborate on any medical conditions indicated above:
Please list all prescription medications, nutrient supplements, or non-prescription medications currently being taken:
Please list all medications to which the patient is allergic:
Is the patient currently being treated by a physician?
Yes
No
Why?
Does the patient need to take antibiotics prior to dental cleaning appointments?
Yes
No
Dental History
Speech Problems
Yes
No
Tonsil or Adenoid Conditions
Yes
No
Chipped or Otherwise Injured Permanent Teeth
Yes
No
TMJ Pain/Clicking/Locking
Yes
No
Sinus Trouble
Yes
No
Thumb/Finger Sucking
Yes
No
Until:
Jaw Fractures/Cysts/Infections
Yes
No
Gum Problems
Yes
No
Abnormal Swallowing/Tongue Thrusting
Yes
No
Mouth Breathing/Snoring
Yes
No
Tooth Grinding/Jaw Clenching
Yes
No
Ringing in Ears (Tinnitus)
Yes
No
Please indicate your primary orthodontic concerns:
Date of most recent dental examination:
Were X-rays taken?
Yes
No
Acknowledgement
I have read and understand the above questions. The information I have given is correct to the best of my knowledge. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice. I authorize the release of any information relating to all insurance claims. I hereby authorize payments directly to the above named dentist of the group insurance benefits otherwise payable to me.
Signature of parent/guardian or patient if over 18 years of age:
Date:
Acknowledgement of Receipt of Notice of Privacy Practices
*You May Refuse to Sign This Acknowledgement*
I have received a copy of this office's
Notice of Privacy Practices
.
Signature:
Date: