Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
Dental Insurance Information
Policy Holder's Name:
Policy Holder's Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Medical History
Physician Name:
Physician Phone:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Select here if all answers BELOW are
NO
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Codeine or other narcotics?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Metal?
No
Yes
Penicillin or other antibiotics?
No
Yes
Sulfa drugs?
No
Yes
Other?
No
Yes
Please list any other drug allergies or sensitivities 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.
Select here if all answers BELOW are
NO
Angina?
No
Yes
Anemia or blood disorder?
No
Yes
Arteriosclerosis?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Bed wetting?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Bone fractures or trauma to face or jaw?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Chronic fatigue?
No
Yes
Diabetes?
No
Yes
Emotional problems treatment?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Heart valves are damaged or artificial?
No
Yes
Hemophilia?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Low blood pressure?
No
Yes
Nervous disorders?
No
Yes
Persistent cough?
No
Yes
Persistent swollen neck glands?
No
Yes
Pneumonia?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Prosthetic joints?
No
Yes
Radiation treatment?
No
Yes
Respiratory problems or emphysema
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Sexually transmitted disease?
No
Yes
Sinus trouble?
No
Yes
Stomach ulcer or hyperacidity?
No
Yes
Substance abuse problem (past or present)?
No
Yes
Thyroid or endocrine problems?
No
Yes
Tonsils enlarged?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
FEMALES: Are You Pregnant?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
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 my orthodontist or any other member of his/her staff 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.
I understand that where appropriate, credit bureau reports may be obtained.