Confidential Patient Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
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:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security # (for insurance verification):
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security # (for insurance verification):
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Do you have dental insurance?
No
Yes
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Phone No.:
Emergency Information
Name:
Best Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the Patient need to premedicate prior to dental visit?
No
Yes
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Previous root canal therapy?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Teeth that irritate tongue, cheek, lip, etc?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently Chew Gum?
No
Yes
Thumb or finger habit as a child?
No
Yes
Jaw Fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Other periodontal (gum) problems?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Have wisdom teeth been removed?
No
Yes
Problems with food trapped between teeth?
No
Yes
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
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/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Codeine or other narcotics
No
Yes
Metal Allergy
No
Yes
Other:
No
Yes
List any drug allergies or sensitivities (not listed above) 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.
Heart Murmur
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital Heart Defect
No
Yes
Heart Disease
No
Yes
Rheumatic Fever
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Large Tonsils
No
Yes
Sinus trouble
No
Yes
Substance abuse problem (past or present)
No
Yes
Bone fractures/trauma to face/jaw
No
Yes
Prosthetic joints
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Tuberculosis or Lung Disease
No
Yes
Pneumonia
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Arteriosclerosis
No
Yes
Thyroid / Endocrine Problems
No
Yes
Stomach ulcer or hyperacidity
No
Yes
Hormone Therapy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Treated for Emotional Problems
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
Sexually transmitted disease
No
Yes
Low blood pressure
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:
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
HIPAA Consent
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.
Agree
Click
here
to read the HIPAA Consent Policy.
Authorization for Cell Phone and Email Use
I give my consent to the orthodontic practice to use my cell phone for appointment, treatment information, insurance and billing information. I understand that I can withdraw my consent at any time.
Choose one:
Phone calls
Text
Both
Neither
I give my consent to receive email communications regarding treatment information, insurance, account and billing information, and special promotions from the orthodontic practice. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I understand that I can withdraw my consent at any time.
No
Yes
Photographic/Media/Social Media Consent
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Honey Orthodontics to use my image, video and photographic likeness and/or any interview statements from me in its office, publications, advertising or ortho media activities (including the Internet and social media sites) for the purpose of informing patients of the positive outcome we have achieved.
I understand that no personal information, such as full names, will be used in any publications unless express consent is given.
I also understand that my consent can be withdrawn at anytime in writing to Honey Orthodontics.
I have read the above statements and I give this consent voluntarily.
Agree
Do not agree
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.