ORTHODONTIC PATIENT INFORMATION AND HEALTH HISTORY
First Name:
Last Name:
Nickname:
Birthdate:
Gender:
Sex:
Pronoun:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
School:
Grade:
Occupation:
Hobbies/Sports:
Whom may we thank for this referral?
Have any other family members or siblings been to our practice?
Email Address for billing and appointment confirmation:
FAMILY (For Patients Under 18)
Father's Name
Relationship to patient:
Biological
Step-father
Adoptive
Occupation:
Employer:
Mother's Name:
Relationship to patient:
Biological
Step-father
Adoptive
Occupation:
Employer:
Parents' Marital Status:
Married
Divorced
Separated
Widowed
Not Married
Patient Living with:
Mother
Father
Other:
PERSON RESPONSIBLE FOR FINANCIAL MATTERS
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Main Phone:
Cell Phone:
Work Phone:
Address:
City:
State:
Zip:
Employer:
Occupation:
PRIMARY DENTAL INSURANCE INFORMATION
Name of Insured:
Insured Soc. Sec./ID #:
Employer:
Relationship to patient:
Insured Birthdate:
Insurance Company:
Insurance Address:
SECONDARY DENTAL INSURANCE INFORMATION
Name of Insured:
Insured Soc. Sec./ID #:
Employer:
Relationship to patient:
Insured Birthdate:
Insurance Company:
Insurance Address:
MEDICAL HISTORY
Patient's Dentist
Name:
Address:
Phone:
Patient's Physician
Name:
Address:
Phone:
Has any other orthodontist been consulted regarding this patient?
Has the patient had previous orthodontic treatment (please explain)?
Please describe any major illnesses or hospitalizations:
Is the patient taking any medications?
Has the patient been under the care of a physician during the past 3 years, other than for routine examination (please explain)?
Has the patient ever had (please check)
Abnormal blood pressure
Yes
No
Abnormal bleeding
Yes
No
ADD/ADHD
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Autism
Yes
No
Autoimmune disorder
Yes
No
Blood/bone disorder
Yes
No
Cancer
Yes
No
Cold sores
Yes
No
Diabetes
Yes
No
Dizziness
Yes
No
Eating disorder
Yes
No
Emotional problems
Yes
No
Endocrine disorder
Yes
No
Epilepsy and/or seizures
Yes
No
Headaches/migraines
Yes
No
Head or face injury
Yes
No
Hearing impairment
Yes
No
Heart disease
Yes
No
Heart murmur
Yes
No
Heart valve condition
Yes
No
Hepatitis
Yes
No
HIV positive status
Yes
No
Kidney disease
Yes
No
Oral ulcers
Yes
No
Rheumatic fever
Yes
No
Sleep disturbances
Yes
No
Speech difficulties
Yes
No
Surgery
Yes
No
Thyroid condition
Yes
No
Tuberculosis
Yes
No
Other (please describe)
LATEX ALLERGY:
Yes
No
Does the patient have any other allergies (List)?
Does the patient require premedication prior to dental treatment?
Has the patient reached puberty (menstruation, voice change) yes or no? If yes, how long ago?
DENTAL HISTORY
Date of last dental visit:
Were the patient's teeth cleaned at this time?
Yes
No
How often does the patient brush his/her teeth?
Is there a history of trauma to any teeth?
Yes
No
If so, please explain:
Has the patient ever had or is there a history of: (please check)
Sucked thumb or fingers
Yes
No
Lip biting or lip sucking
Yes
No
Nail biting
Yes
No
Clenching or grinding teeth
Yes
No
Pain/Clicking/Popping around the ear or jaw joint (TMJ)
Yes
No
Tongue thrust habit or other functional problem
Yes
No
Frequent sore throats or tonsillitis
Yes
No
Mouth breathing or snoring
Yes
No
Pain or difficulty when chewing
Yes
No
What is the patient's primary concern? What brings you to the office today?
What is expected from orthodontic treatment?
What is the patient's interest in treatment?
Wants treatment
Only if necessary
Unwilling
but will cooperate
Uncooperative
Realizing that successful 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?