Patient Biographical Information

Patient
Today's Date
Address
City
State
Zip
Home Phone #
Cell #
Work Phone #
Patient's Date of Birth
Age
Email
How did you find us?
If you were referred, whom may we thank for referring you?
Chief Orthodontic Concern
Dentist
Date of Last Exam
Emergency Contact
Relation
Phone #
Parent/Primary Insurance Max $
Name
DOB
Relationship to Patient
Address
City
State
Zip
Home Phone #
Cell #:
Work #:
Employer:
Address:
Orthodontic Insurance Company:
SS/ID #:
Ins Co Address:
City:
State:
Zip:
Spouse/Parent Secondary Insurance Max $
Name
DOB
Relationship to Patient
Address
City
State
Zip
Home Phone #
Cell #:
Work #:
Employer:
Address:
Orthodontic Insurance Company:
SS/ID #:
Ins Co Address:
City:
State:
Zip:
Check all that are applicable, either now or in the past:
  Allergies 
  Liver Disease/Kidney Disease
  Cold Sores
 Asthma
 Rheumatic Fever
 Venereal Disease
  High/Low Blood Pressure
  Diabetes Type I or II
  Tuberculosis/Chronic Cough
  Cancer/Chemotherapy
  Hypoglycemia
  Hemophilia/Sickle Cell Anemia
  Arthritis/Rheumatism
  Hepatitis - A, B, or C 
  Blood Transfusion
  Lupus/MS
  Joint Replacement (Knee, Hip, etc.)
  AIDS/HIV Positive
  Osteoporosis Treatment
  Heart Disease/Valve Replacement
  Tooth Pain/Sensitivity
  Seizures/Epilepsy
  Heart Failure/Murmur
  Jaw Pain or Headaches
  Thyroid/Endocrine Problems
  Angina/Chest Pain
  Psychiatric Treatment
  Latex Allergy
  Eating Disorder
  Drug Addiction
  Use Tobacco Products
  Herpes
  Surgery 
Are you currently under the care of a physician?
Have you ever been treated for bone problems?
Have you taken any medicine or drugs in the past two years?  
Do you have any disease or problem Not listed?  
The answers to the health questions are accurate and complete. I will notify Dr. Okubo of any change in my health information or medications at subsequent appointments. Before X-Rays are taken I will inform you if I am Pregnant or might be. Dr. Okubo’s HIPAA policy has been made available. I authorize Dr Okubo to perform an exam, radiographs and treatment. I authorize the release of my dental and medical records to Dr. Okubo
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