Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Address:
City:
State:
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:
Cell Phone:
2nd Phone:
Email:
Social Security #:
Orthodontic concerns:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
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:
Cell Phone:
2nd Phone:
Work Phone #:
Employer:
Occupation:
Social Security #:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
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:
Cell Phone:
2nd Phone:
Work Phone #:
Employer:
Occupation:
Social Security #:
Dental Insurance Information
Primary Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Secondary Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Flexible Spending Accounts
Primary Account Holder's Name:
Relationship to Patient:
Flex Plan Company:
Available Balance for Current Plan Year:
Maximum Annual Amount Allowed:
Annual Renewal Date:
Secondary Account Holder's Name:
Relationship to Patient:
Flex Plan Company:
Available Balance for Current Plan Year:
Maximum Annual Amount Allowed:
Annual Renewal Date:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Speech problems/therapy?
No
Yes
Clench or Grind Teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Requires Premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
List any medications currently being taken by the patient:
List any drug allergies or sensitivities the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Arthritis
No
Yes
Asthma
No
Yes
Bone Disorders/Bone Loss
No
Yes
Cancer
No
Yes
Congenital Heart Defect
No
Yes
Endocrine Problems
No
Yes
Ever Been Hospitalized
No
Yes
Growth Problems
No
Yes
Handicaps/Disabilities
No
Yes
Heart Attack/Stroke
No
Yes
Heart Disease
No
Yes
Heart Murmur
No
Yes
Hemophilia
No
Yes
Hepatitis
No
Yes
HIV/AIDS
No
Yes
Hormone Therapy
No
Yes
Hypertension/High Blood Pressure
No
Yes
Latex/Metal Allergy
No
Yes
Liver Disease
No
Yes
Nervous Disorders
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Received Radiation Treatment
No
Yes
Rheumatic Fever
No
Yes
Seizures/Epilepsy
No
Yes
Treated for Emotional Problems
No
Yes
Tuberculosis/Lung Disease
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
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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 Kim Orthodontics LLC, Dr. Gerald Kim, or any other member of the organization 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.
*
By checking this box, you agree that we may use or disclose your protected health information to carry out treatment, payment, healthcare operations and other normal business activities as it relates to treating you or your dependent.