Confidential Patient Information

Last Name:

First Name:

Middle Initial:

Preferred Name:

Address:

City:

State:

Zip:

Home Phone:

Date of Birth:

Age:

Sex: Male Female

S.S.N.:

Email:

Work Phone:

Cell Phone:

Employed By:

Occupation:

Favorite Sports, Hobbies & Avocations:

Children? Name(s):

Age(s):

Spouse's Name:

S.S.N.:

Employed By:

Work Phone:

Other:

Employer Address:

Occupation:

Responsible Party Information

Name of Person Responsible for Account:

Relationship to Patient

Home Address (if different from above)

S.S.N.:

Employed by:

Work Phone:

Occupation:

Do you have Dental Insurance? Yes No

(If Yes please provide us with a copy of your insurance card)

In case we cannot reach you, person(s) to contact:

Phone Number:

Medical History

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing orthodontic treatment. All information will be kept completely confidential.

Physician's Name:

Address:

Phone:

Are you in good health? Yes No

Explain:

Do you have a history of major illness? Yes No

Explain:

Are you presently under the care of a physician? Yes No

Explain:

Are you presently taking any medications? Yes No

List:

Do you take pre-medication for dental procedures? Yes No

List:

Are you allergic to any metals or other products (i.e. latex, nickel)? Yes No

List:

Are you allergic to any drugs, foods, etc.? Yes No

List:

Have you taken any medications for osteoporosis? (Fosomax, Boniva, Actonel) Yes No

List:

Have you undergone chemotherapy for any diseases of the bone? Yes No

Describe:

Have you had a heart defect? (murmur, heart valve) Yes No

List:

Have you had surgery that involves the placement of a prosthesis (hip/knee replacement, heart, valve replacement)? Yes No

Describe:

Have you had surgery or radiation treatment for a tumor or growth in the head and neck area? Yes No

Describe:

If female, are you or might you be pregnant? Yes No

Please check if you have had any of the following conditions:

HIV Positive/AIDS

Hepatitis Type

Liver Disease/Jaundice

Rheumatic Fever

Rheumatic Heart Disorder

Scarlet Fever

Heart Murmur

Heart Trouble/Surgery

Heart Valve Defects

Tuberculosis

High/Low Blood Pressure

Diabetes

Bleeding Problems

Lung Disease

Epilepsy/Seizures

Arthritis

Lupus/CT Disease

Kidney Disease

Allergies

Asthma/Lung Disease

Cancer

Anemia

Glaucoma

Degenerative Joints

Thyroid Problems

Venereal Disease

Rheumatoid Arthritis

Stomach Ulcers

Gastric Reflux

Polio

Mononucleosis

Substance Abuse

Migraine Headaches

Emotional Problems

Stroke

Frequent Headaches

Endocrine Problems

Nervous Disorders

Bone Disorders

Facial Pain

Bulimia

Anorexia Nervosa

Muscular Disorder

Fainting Spells

Other

COMMENTS:

Dental History

Dentist's Name:

Address:

Phone:

Please check any of the following conditions for which you have been diagnosed or treated:

Facial/Teeth/Jaw Injury

TMJ/TMD/Jaw Problems

Grinding/Clenching Habit

Jaw Clicking/Popping

Jaw Locking

Tongue Thrust

Bleeding Gums

Receding

Gum Disease

Lip Biting

Dead Teeth/Root Canal

Tooth Sensitivity

Chipped or Broken Teeth

Thumb or finger habit

Facial Pain

Ringing in the Ears

Cold Sores

Mouth Ulcers

Jaw Cysts/Tumors

Missing Teeth

Mouth Breathing

Impacted Teeth

Receding Jaw

Other

COMMENTS:

Which of the following are significant concerns?

Crooked/Crowded Teeth

Impacted Teeth

Spaced Teeth

Under Developed Jaw

Over Developed Jaw

Tooth Wear

Extra Teeth

Wisdom Teeth

Missing Teeth

Portruding Teeth

Overbite

Other

What would you change about your teeth or smile?

What treatment options interest you? Clear Aligners
Braces
Retainers
Other

How soon would you like to start if treatment is recommended? ASAP
Within the Month
Within 6 Months
Other

What payment option(s) would you like to know more about during your appointment? Payment-in-Full w/Discount
No-Interest Monthly Payments
Health Savings Account
Other

Have you had a prior orthodontic exam or prior orthodontic treatment? Yes No

Are you currently under a general dentist's care? Yes No

When was your last dental exam and cleaning?

Realizing that succussful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment?

If so please explain:

I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to thi history record or medical/dental status I will so inform this practice.

I consent to the taking of x-rays, models and photographs necessary for diagnostic purposes.

I agree to be responsible for dental services and materials not paid by my dental benefit plan and to the extent permitted under applicable law. I authorize release of any information relating to this claims. I also hereby authorize payment of the dental benefits otherwise payable to me directly to Dr. Michael S. Wall, DMD.