Confidential Patient Information

Date:
Last name:
First name:
Middle initial:
 Title: 
Prefers to be called:
Hobbies/Activities:
School:
Birth date:
Age:
Gender:
Social Security #:
Home address:
City:
State:
Zip:
Home phone:
Cell phone:
Work phone:
Email address(es):
Occupation:
Employer:

Parent/Guardian (Patients Under 18)

Custodial parent(s) name(s):
Patient lives with: (check all that apply)
  
Father’s full name:
 Title: 
Occupation:
Email address:
Address (if different):
Home phone (if different):
Cell Phone:
Work phone:
Mother’s full name:
 Title: 
Occupation:
Email address:
Address (if different):
Home phone (if different):
Cell Phone:
Work phone:

Financial Responsibility

Who is financially responsible for this account?
Address:
Home phone:
Cell phone:
Email address:
Social Security #:
Employer:

Medical Insurance

Policy holder’s full name:
Insurance company:

Dental Insurance

Primary policy holder’s full name:
Birthdate:
Social Security #:
Relationship to patient:
Address and phone:
Employer:
Address:
Insurance company:
Group #:
ID #:
Does this policy have orthodontic benefits?
Secondary policy holder’s full name:
Birthdate:
Social Security #:
Relationship to patient:
Address and phone:
Employer:
Address:
Insurance company:
Group #:
ID #:
Does this policy have orthodontic benefits?

General Information

What concerns you about yours/ your child’s teeth?
What concerns you/your child about your/their teeth?
How do you/your child feel about orthodontic treatment?
Who suggested that you/your child may need orthodontic treatment?
Why did you select our office?
Who referred you to our office?
Describe any previous orthodontic treatment or consultations. Where? Year?
Has the patient ever worn a retainer or space maintainer before? Explain:
Do you/your child play a musical instrument?
Sibling name:
Age:
Had orthodontic treatment?
Where?
Sibling name:
Age:
Had orthodontic treatment?
Where?
Sibling name:
Age:
Had orthodontic treatment?
Where?
Have any other family members been treated in our office? Please name them.

Medical History

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don’t know (dk).For the following questions, please mark yes, no, or don’t know (dk).
Now, or in the past, have you/your child had:
Birth defects or hereditary problems?
Bone fractures or major injuries?
Any injuries to face, hand, neck?
Cancer, tumor, radiation, chemotherapy?
Arthritis of joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Stomach ulcers, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, STDs?
AIDS or HIV positive?
Hepatitis, jaundice, other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, epilepsy, fainting, neurologic problems?
Mental health disturbances or depression?
Vision, hearing, or speech problems?
History of eating disorder?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding, bruising tendency, anemia?
Chest pain, shortness of breath, tire easily?
Heart defects, murmur, rheumatic disease, Mitral valve prolapse?
Angina, arteriosclerosis, stroke, heart attack?
Skin disorders (other than common acne)?
Do you eat a well-balanced diet?
Frequent colds, ear or throat infection, chronic cough?
Asthma, sinus problems, hay fever?
Tonsil or adenoid condition? Removed?
Have you ever taken IV bisphosphonates?
Have you ever taken oral bisphosphonates?
Sensory disorder
Autism
ADHD
Describe any dental or facial trauma:Describe any dental or facial trauma:
(Patient under 18)
Females: Age when menstruation began:
Have you/your child had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine)
Latex (gloves)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Metals (jewelry, clothing)
Acrylics
Plant pollens
Animals
 Foods 
 Other 

Dental History

Now, or in the past, have you/your child had:
Permanent or extra teeth removed?
Any extra or missing teeth?
Chipped, injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste, or mouth odor?
Jaw fractures, cysts, infections?
Teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems, speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Abnormal swallowing (tongue thrust)?
Teeth causing irritation to lip, cheek, gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Been treated for TMJ or TMD problems?
Any serious trouble associated with previous dental treatment?
Frequent oral habits (ex chewing pen, ot)?
Any difficulty chewing or swallowing food?
Have you ever been diagnosed with gum disease or pyorrhea?
How often do you/your child brush?
How often do you/your child floss?

Patient Health Information

List any medications, nutritional supplements, herbal medications or non-prescription medications that you/your child take:
Medication:
Taken for:
Medication:
Taken for:
Medication:
Taken for:
Have you/your child ever taken any medications to strengthen your/their bones? Please describe.
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Any other physical problems?
Women: Are you pregnant?
Are you trying to become pregnant?

Family Medical History

Have you/your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions

Medical History Updates

Changes:
Signature:
Date:
Dental Staff Signature:
Date:
Changes:
Signature:
Date:
Dental Staff Signature:
Date:
Changes:
Signature:
Date:
Dental Staff Signature:
Date:

Dentist

Dentist:
Address:
Last seen:
Reason:
Next appointment:
Other dentists/dental specialists being seen:
City:
Reason:

Physician

Physician:
City, State:
Phone #:

Release and Waiver

I authorize and release any information regarding mine or my child’s orthodontic treatment to mine or my child’s dental and/or medical insurance company.
Signaure:
Date:
I have read the above questions and understand them. I will not hold my orthodontists or any member of their staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontists of any changes in mine or my child’s medical or dental health.
Signature of Patient(Parent/Guardian for patients under 18)
Date