Confidential Patient Information
*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Cell Phone:
Home Phone:
Email:
Whom may we thank for referring you to our practice?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, parents are:
Select...
Single
Married
Partnered
Widowed
Divorced
Separated
If patient is a minor, who does the patient live with?
Select
Father
Mother
Parents
If the patient is a minor, I consent for Lovell Orthodontics to disclose protected health information regarding this patient to the following authorized parties (this allows other family members to obtain information about the patient’s treatment or schedule appointments for the patient)
Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
*Address:
*City:
*State:
*Zip:
Email:
*Cell Phone:
Home Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Employer:
Occupation:
Work Phone #:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental Insurance Information
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Orthodontic Concerns
Has the patient had a previous orthodontic consult or treatment?
No
Yes
If so, when and where?
What is the patient's main orthodontic problem as you see it?
Indicate your concern for correcting the problem:
Very Concerned
Concerned
Indifferent
Opposed
Does anyone in the family have similar dental or facial conditions? Who?
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Is all dental work completed at this time?
No
Yes
Does the patient need to premedicate prior to dental visit?
No
Yes
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Tonsils or Adenoids removed?
No
Yes
Frequent headaches or jaw pains?
No
Yes
Frequent nasal obstruction earaches, or sore throats?
No
Yes
Accidents or trauma to face or teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Speech/Hearing Difficulties?
No
Yes
Clench or Grind Teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Mouth breathing?
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
Address:
City:
State:
Zip:
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/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
List any drug or environmental 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. Cannot be blank.
Rheumatic Fever or Rheumatic Heart Disease
No
Yes
Heart Problems
No
Yes
Pneumonia or Lung Disease
No
Yes
Kidney Disease or Diabetes
No
Yes
Hypertension/High Blood Pressure
No
Yes
Anemia, Hemophilia, or Prolonged Bleeding
No
Yes
Hepatitis/Tuberculosis/HIV/AIDS
No
Yes
Prosthetic Joints
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Nervous Disorders
No
Yes
Seizures / Epilepsy
No
Yes
Emotional/Learning Problems
No
Yes
Asthma
No
Yes
Handicaps/Disabilities
No
Yes
Does patient use tobacco products?
No
Yes
FEMALES: Are you pregnant?
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
School:
Grade:
Indicate the child's level of concern for correcting the orthodontic problem:
Very Concerned
Concerned
Indifferent
Opposed
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Has either biological parent ever had orthodontic treatment:
Don't know
No
Yes
Name of orthodontist: